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9 



LIPPINCOTTS NEW MEDIC^L^EklJS^ 

Edited by FRANCIS R. PACKARD, M.D. 

RONTGEN RAYS 

AND 

ELECTRO-THERAPEUTICS^ 

WITH CHAPTERS ON RADIUM 
AND PHOTOTHERAPY 

BY,/ 

MIHRAN KRIKOR KASSABIAN, M.D. 

Director of the Rontgen Ray Laboratory of Philadelphia General Hospital ; Formerly in charge of the 
Rontgen Ray Laboratory and Instructor in Electro-Therapeutics in Medico-Chirurgical 
Hospital and College ; Member of the Philadelphia County Medical Society ; 
Pennsylvania State Medical Society ; American Medical Association ; 
Vice-President of the American Rontgen Ray Society ; Vice-Pres- 
ident of the American Electro-Therapeutic Association. 



SECOND EDITION 




PHILADELPHIA 6^ LONDON 
J. B. LIPPINCOTT COMPANY 



,S05Tc 



i a 



Copyright, 1907, by J. B. Lippincott Company 
Copyright, 1910, by J. B. Lippincott Company 



TO ^ 

MT MOTHER AND MY BROTHERS 

I DEDICATE THIS VOLUME 
AS A TOKEN OF KESPECT AND AFFECTION. 

THE AUTHOR. 



'You go not till I set you up a glass, 
Where you may see the inmost parts of you." 

HAMLET, Act III. Scene IV. 



" In wonder all philosophy began, in wonder 
it ends, and admiration fills up the interspace ; but 
the first wonder is the offspring of ignorance, the 
last is the parent of adoration." 

COLERIDGE. 



PREFACE TO SECOND EDITION 



THE very favorable reception accorded the author's volume on (i Elec- 
tro-Therapeutics and Eontgen Eays ' ' has induced him to spare no effort 
to bring the work thoroughly up to date ; and with the many added sub- 
jects, and the condensations and corrections in various parts of the original 
text, he believes the present volume is much superior to its former self. 

Of the score of special articles just incorporated in the following 
pages, special attention is invited to the subjects of Ionic Therapy, Elec- 
tric Sleep and Fulguration. The advances wrought in the past year or 
two in the development of improved apparatus greatly enlarge that divi- 
sion of the volume. 

To the second part of the book have been added elaborate accounts 
of Instantaneous Eontgenography, Telerontgenography, Chromo-Stereo- 
Eontgeuography and Plastic Eontgenography. Some minor changes and 
a consideration of Kromayer's lamp will be noted in Part III. 

A special feature which it is thought will materially add to the value 
of the work is the introduction in the present edition of the photographic 
illustrations of technic. 

M. K. K. 

PKOFESSIONAL BUILDING, 

Philadelphia, Pa., February, 1910. 



PREFACE TO FIRST EDITION 



THE object of this book, as indicated by its title, is to present, 
clearly and concisely, the more important facts pertaining to electro- 
therapeutics and the Rontgen rays. Notwithstanding the many valuable 
and important treatises extant on both these subjects, the author has 
keenly felt the need of something more, and he has endeavored to offer, 
in a condensed but comprehensive manner, the theories and applications 
of electrical energy, in its various forms, to the domain of medicine. 

The initial portion of the work is devoted to the subject of electro- 
therapeutics, whose compendious character, it is believed, will appeal 
to the practical physician. Beginning with the definition of electrical 
terms, this division of the work gradually leads the reader to an elaborate 
description of high-frequency currents, which have recently opened up so 
fertile and promising a field. As in other portions of the volume, the 
introduction of debatable questions and mathematical formulas has been 
studiously avoided, and no space has been encumbered with the recital 
of fanciful theories or those of a controversial nature. 

An exhaustive study of the Rontgen rays follows. The author has 
bestowed much care to a description of the apparatus employed, believing 
that its thorough mastery is essential to a complete understanding of the 
subject. The technic of radio -photography is treated of at length, be- 
cause an intimate knowledge of this department is indispensable for the 
production of successful skiagraphs, and if the chapter on stereo-skia- 
graphy seems extensive, it is due to the fact that the author regards the 
subject as one of constantly growing importance. A word regarding 
X-ray dosage. Lack of a standard unit of measurement in X-ray therapy 
has compelled the lengthy discussion of the various methods in vogue. It 
is believed, however, that this is a valuable addition to the work, and 
may perhaps prove a convenience to many, who find the literature on 
this subject to be widely scattered. Much thought has been bestowed on 
the technic of dental skiagraphy, and the same may be said of the chapter 
on the localization of foreign bodies. With an experience of more than 
eight thousand cases under his immediate study and care, the author has 
preferred, wherever possible, to introduce and quote the views of his 
confreres, rather than to obtrude his own opinions as the only ones accept- 
able. Because of the importance of the subject, much space has been 
assigned to a study of the cathode rays, and to the terse and elegant 
description of the Rontgen rays, so simply told by Rontgen and so faith- 
fully translated by Professor Barker for Harper and Brothers. 



viii PEEFACE. 

The therapeutic value and the limitations of radium are being thor- 
oughly investigated, and it is still too early to assign any definite place to 
this remarkable agent in the practice of medicine. A space, all too 
brief, is allotted to the study of phototherapj-, and to the memorable 
discoveries which the genius of Finsen bequeathed to science. 

A striking feature, which will materially add to whatever merit the 
work may possess, is the introduction, in its final pages, of a study of the 
technic employed and the remarks made by many of the leading expo- 
nents of Eontgen therapy both in this country and in Europe. 

In the department of electro-therapeutics the author has freely con- 
sulted the works of Eockwell, H. Lewis Jones, Erb, Hedley, and Snow. 

In the portion devoted to the Eontgen rays he has referred to the 
treatises of Caldwell and Pusey, F. Williams, Freund, Bouchard, Isen- 
thal and Ward, and Hyndman. 

I wish gratefully to acknowledge my indebtedness to Dr. Samuel 
Lewald, of this city, who, by his literary skill and unceasing interest in 
the preparation of the present volume, has greatly lightened the labor of 
it. A word of thanks is due my colleagues Drs. Charles L. Leonard and 
William M. Sweet ; the former for many suggestions, the latter for 
valuable advice in regard to the chapter on localization. Mr. H. C. 
Snook very kindly offered several practical hints on the X-ray apparatus. 
I am only too conscious of the courtesies shown me by Dr. Francis E. 
Packard, the editor of Lippincott's New Medical Series. 

In conclusion, it seems fitting to remark that to his friends and to the 
many friends of science, who have urged him on, and encouraged him to 
the consummation of the present volume, the author feels profoundly 
grateful. 

MIHEAN K. KASSABIAN. 
PROFESSIONAL BUILDING, 

Philadelphia, Pa., June, 1907. 



CONTENTS 



INTRODUCTION. 

PAGE 

HISTORICAL SKETCH OP THE RISE OF ELECTRICITY xxxvii-xxxix 

ELECTRICITY AS A PART OF THE MEDICAL CURRICULUM xxxix, xl 



PART I. 
ELECTRO-THERAPEUTICS. 



CHAPTER I. 

ELEMENTARY PRINCIPLES OF ELECTRICITY -AND MAGNETISM. 

I. Nature and Properties of Magnetism 5 

MAGNETS NATURAL 5 

ELECTRO-MAGNETS 5 

II. Nature and Properties of Electricity 6 

A. THEORY OF POTENTIAL 6 

(a) Hydraulic Analogy 6 

B. UNITS OF ELECTRICAL MEASUREMENT, C. G. S. SYSTEM 8 

(a) Electro-static Units 8 

(b) Magnetic Units 8 

(c) Electro-magnetic or "Absolute" C. G. S. Units 9 

(d) Practical Units and Standards 9 

C. DEFINITIONS AND EQUATIONS 10 

Conductivity 10 

Resistance: Ohm's Law 11 

Ampere; Farad; Watt; Equations 11 

III. Sources of Electrical Energy 11 

A. STATIC 11 

B. GALVANIC 11, 12 

(a) Primary Batteries: Construction and Connection 12 

1. Series 12 

2. Parallel 12 

3. Group 13 

(b) Accumulators, Storage or Secondary Batteries 13 

Principles; Varieties 13, 14 

Capacity 14 

Charging from 

1. Primary Cells 15 

2. 110-Volt (direct) Current 16 

3. Alternating Current 16 

4. Bicycle 17 

5. Thermopiles 17 

ix 



x CONTENTS. 

PAOM 

C. DYNAMIC OR ELECTRIC MAINS 17 

(a) Direct 17 

(b) Alternating 17 

D. THERMOPILES 17 

CHAPTER II. 
THE STATIC, FRANKLINIC, OR FRICTIONAL CURRENT. 

I. The Static or Influence Machines 18 

Principles of Construction 18 

A. TYPES OF INFLUENCE MACHINES 19 

Theory of Action (Wimshurst) 19 

Theory of Action (Holtz) 21 

Theory of Action (Voss or Toepler) 22 

B. CARE AND MANIPULATION OF STATIC MACHINES 23 

C. ACCESSORIES 24 

The Leyden Jar 24 

Electrodes 24 

Chain-Holder 25 

Muffler 26 

Preparation of the Patient 26 

Polarity 26 

Idiosyncrasy 27 

Dosage 28 

II. The Modes of Application 29 

A. CONVECTIVE CURRENTS 29 

Brush Discharge; Breeze and Spray 29 

Static Bath; Interrupted Insulation 29 

B. DISRUPTIVE CURRENTS 30 

Direct; Indirect; Frictional 30 

C. CONDUCTIVE CURRENTS 30 

Static Induced Current 30 

Wave Current (Morton) 30, 31 

STATIC MODALITIES (CHART) 32, 33 

CHAPTER III. 
GALVANIC, CONTINUOUS, OR DIRECT CURRENT. 

Galvanic Battery; Connections 34 

Types of Cells 35 

Care of Battery; Charging the Cells; Polarity 36 

Wall Cabinet 36 

Rheostat; Electrodes; Galvanometer; Milliamperemeter 38 

Galvano-Faradic Box 39 

Definition of Terms 39 

Methods of Application 40 

Central Galvanization; Galvano-Faradization 41 

Cautery Batteries 41 42 

Sinusoidal Current 42 



CONTENTS. 



XI 



CHAPTER IV. 

FARADIC, INTERRUPTED, OR INDUCED CURRENTS. FAOB 

Principles of Induction 43 

Faradic Battery 43 

Medical Induction Coil 43, 44 

Interrupter or Rheotome 45 

Method of Application 45 

Localized Faradization 46 

As a Diagnostic Agent 46 

As a Therapeutic Agent 46 

CHAPTER V. 
CATAPHORESIS. IONIC THERAPY. HYDRO-ELECTRIC BATH. 

I. Cataphoric Method 47 

II. Ionic Therapy 49 

A. Theory of Ions 49 

B. Penetration of Ions through Integument 50 

C. Therapeutic Action as a Result of Dissociation 51 

D. Resistance of the Human Body 52 

E. Investigators of the Ionic Theory 52 

F. Electrolytic Applications in Therapeutics 52 

G. Medicaments used as Cathions 53 

III. Hydro-Electric Baths 53 

CHAPTER VI. 
ELECTRO-DIAGNOSIS. 

The Motor Points 57 

Upper Limb 58 

Lower Limb 58 

Face ' 58 

Neck 63 

Segments 64 

Usu|d Nerve Supply 65 

Hints for Practical Testing 65 

Reaction of Degeneration 66 

Degeneration of Muscles 66 

Partial Reaction of Degeneration 67 

Electrical Reactions as a Diagnostic Aid 67 

In Health 67 

In Disease 68 

Sensory System; Nerves of Special Sense 69 

CHAPTER VII. 
ELECTRO-PHYSIOLOGY. 

Influence of Electricity upon Motor Nerves and Muscles 70 

Pfliiger's Laws of Contraction 70 

Upon Voluntary Muscles 72 

Electrotonus 72 

Sensory Cutaneous Nerves 73 



xii CONTENTS. 

PAGE 

Sensory Nerves of Muscles "3 

Upon the Special Senses 73 

Upon the Sympathetic System 74 

Upon the Skin 75 

Upon the Head 75 

Upon the Spinal Cord 75 

Upon the Abdominal Organs 75, 76 

Electrical Currents in Disease 76 

Electrical Sleep 76 

A. Electro-Physiological Data 77 

B. Production of Electric Sleep 77 

C. Local Electrical Anaesthesia 78 

CHAPTER VIII. 
PKACTICAL, APPLICATIONS IN DISEASED CONDITIONS. 

I. Cutaneous System 79 

Acne; Eczema; Pruritus; Alopecia; Sycosis 79 

Hypertrichosis 80 

Psoriasis and Pityriasis; Ringworm and Scleroderma; Prurigo 81 

Cutaneous Anaesthesia, Herpes Zoster 81 

Nsevus; Port-wine Mark; Moles and Warts; Furuncles and Carbuncles. 82 

II. Muscular System 83 

Myalgia; Writer's Cramp 83 

Torticollis; Muscular Contractions; Hemiplegia 84 

Myasthenia Gravis 85 

III. Articular System 85 

Synovitis; Hydro-arthritis; Rheumatoid Arthritis 85 

Chronic Articular Rheumatism; Gout; Tuberculous Arthritis 86 

Fibrous Ankylosis 86 

IV. Digestive System 87 

Vomiting; Dilatation of Stomach 87 

Nervous Dyspepsia 88 

Constipation Method of Application 88 

Enteritis 89 

Fissure of the Anus 90 

Prolapse of the Rectum 90 

Hemorrhoids 90 

Stricture of the Rectum 90 

V. Gemto-Urinary System 90 

Stricture of the Male Urethra , 91 

Prostatitis 93 

Paralysis of the Urinary Bladder 94 

Incontinence of Urine; Nocturnal Incontinence 95 

Spermatorrhoea and Seminal Emission 95 

Impotence 96 

Orchitis 96 

Nephritis 96 



CONTENTS. xiii 

PAGE 

VI. Nervous System 96 

Neuralgias: Cephalalgia, Tic Douloureux, Peripheral Neuralgia, Sci- 
atica 96-98 

Paralyses: Rheumatic Paralysis, Syphilitic Paralysis, Lead, Arsenic, 

Opium, etc 98 

Hemiplegia; Paraplegia 98 

Facial Paralysis; Poliomyelitis; Locomotor Ataxia 99 

Chronic Spinal Muscular Atrophy 99 

Epilepsy 99 

Insomnia; Hysteria; Hypochondriasis and Melancholia 100 

Insanity; Neurasthenia 100 

Exophthalmic Goitre 101 

VII. Gynaecology 102 

Limitations and Possibilities in the Treatment of Diseases of Women . . 102, 103 

Amenorrhoea 104 

Dysmenorrhcea 104 

Fibroid Tumors 104 

Ovarian Tumors 105 

Chronic Metritis 105 

Periuterine Hsematocele 105 

Stenosis of the Cervical Canal 105 

Subinvolution and Atrophy 105 

Urethral Caruncle 105 

Post-partum Hemorrhage 105 

Vomiting of Pregnancy 106 

Slow Labor 106 

VIII. Aneurism 107, 108 

CHAPTER IX. 
APPLICATIONS IN THE SPECIALTIES. 

I. Rhinology and Laryngology 109 

Atrophic Rhinitis; Pharyngitis; Oza3na 109 

Anaesthesia of the Pharynx; Laryngeal Fatigue 110 

Atrophic Pharyngitis; Anosmia 110 

Asthma Ill 

II. Otology Ill 

Auditory-Nerve Deafness Ill 

Chronic Suppuration of the Middle Ear Ill 

Tinnitus Aurium 112 

Electricity in Otology (Richardson) 112-114 

III. Ophthalmology 114 

Paralysis of the Muscles of the Eye 114 

Blepharospasm 114 

Cataract 115 

Electrolysis in Diseases of the Lacrymal Canal 115 

Retinal Anaesthesia and its Treatment by Voltaic Alternatives 115 

Miscellaneous Ophthalmic Affections 116 



xiv . CONTENTS. 

CHAPTER X. 
HIGH-FREQUENCY CURRENTS. 

PAO 

I. Historical Introduction 118 

II. Principles and Apparatus 119 

Morton's "Static Induced Current " High-Frequency Apparatus 120 

D'Arsonval High-Frequency Apparatus 121 

Tesla's High-Frequency Apparatus 122 

The Oudin Resonator 123 

Glass Vacuum Electrodes 123 

Cataphoresis Electrodes 124, 125 

III. Physical Properties 125 

A. INDUCTION EFFECTS 125 

B. ELECTRO-STATIC EFFECTS 125 

C. DYNAMIC PROPERTIES .' 125 

D. RESONANCE 126 

IV. Methods of Application 126 

1. Direct Application 126 

2. Indirect Application or Auto-conduction by the Solenoid 127 

3. Auto-condensation 128 

4. By Local Application 128 

V. Physiological Properties 128 

VI. Applications in Various Diseases 129 

Tuberculosis 129 

Gout; Rheumatism; Obesity 130 

Hysteria 131 

Lupus Vulgaris 131 

Rodent Ulcer and Malignant Diseases 131 

Piles, Rectal Fissures, and Pruritus Ani 131 

Colitis 132 

<>/: i n : i 132 

Epilepsy 133 

Skin Diseases 134 

Trachoma 134 

Dulness of Hearing and Subjective Noises 134 

Gonorrhoea 135 

Fulguration 136 

A. Apparatus 136 

B. Technic 136 

C. Dosage 137 



CONTENTS. xv 

PART II. 
THE RONTGEN RAYS IN DIAGNOSIS. 

PAGE 

Historical Introduction 140 

1650, Otto von Guericke 140 

1740, Abbe Nollet 140 

1834, Sir W. Snow Harris 140 

1838, Michael Faraday 140 

1838, Heinrich Geissler 140 

1840, Clerk Maxwell 140 

1860, Sir Wm. Thomson (now Lord Kelvin) 140 

1865, Gassiot and Sprengel 140, 141 

1869, Hittorf 141 

1876, Goldstein 141 

1877, Warren de la Rue, Hugo Muller, and W. Spottiswoode 141 

1879, Sir Wm. Crookes 141 

1883, Wiedemann and J. J. Thomson 141 

1883-1894, Hertz .' 141 

1895, Lenard, Perrin, Elster and Geitel, Rontgen 141 

Comparative Study of the Properties of the Cathode and the Rontgen Rays 142 

CATHODE RAYS 142 

Production; Radiability 142 

Fluorescence and Phosphorescence 143 

Reflection, Refraction, and Polarization 143 

Chemical Effects; Physiological Effects 143 

Various Theories 143 

RONTGEN RAYS 144 

Production 144 

Radiability and Penetrative Power 144 

Fluorescence and Phosphorescence 145 

Reflection, Refraction, Polarization, and Interference 146-150 

Chemical Effects 150 

Physiological Effects; Various Theories 151 

Visibility of the Rontgen Rays 151 

Velocity of Propagation of the X-Rays 151 

Velocity of the Rontgen Rays 152 

Charging Action of the Rontgen Rays 152 

CHAPTER I. 
THE RONTGEN-RAY APPARATUS AND ITS MANIPULATION. 

I. The Induction Coil 153 

A. FARADAY ON THE ELEMENTARY LAWS OF INDUCTION 153 

B. THE CONSTRUCTION OF THE INDUCTION COIL 155 

Primary and Secondary Coil 155 

Condenser and Commutator 155, 156 



xvi CONTENTS. 

PAGE 

C. INTERRUPTERS 156 

(a) Mechanical 156 

Platinum 156 

Vibrating Hammer 156 

Independent 156 

Self-Starting 157 

Vril 157 

Mercury 157 

Dipper 157 

Rotary 157 

Disk 158 

Johnston 158 

Jet... 159 

(b) Electrolytic 159 

Wehnelt 159 

Caldwell and Simon 162 

D. VARIETIES OF INDUCTION COILS 162 

^a) Variable Primary Induction Coil (" Jumbo ") 162, 163 

(b) Tesla Coil 164 

(c) Kinraide 165-167 

(d) Gaiffe 168 

(e) Coil without Interrupter; Max Levy; Grisson 168 

Scheidel-Western Coil 169 

The Snook-Rontgen Apparatus 171 

X-ray Apparatus without an Interrupter 172 

100-plate Static machine 174 

II. Discharges in Partial Vacua and the Crookes Vacuum Tube 175 

A. VARIETIES, TYPES, CONSTRUCTION, AND PRINCIPLES 179 

(a) Stationary Vacuum 179 

(b) Self -Regulating and Regenerative 179 

Heat 180 

Method by Osmosis 184 

Mechanical Regeneration 184 

Electro-static Regeneration 185 

Water-cooling 185 

B. THE QUALITY OF THE X-RAYS 185 

Kind of Electrical Energy Employed 185 

Condition of the Tubes 185 

Soft, Medium, and Hard Tubes 185 

X,-rays, X 2 -rays, X 3 -rays, Porter 185 

Hard, Medium, Soft, Very Soft, Albers-Schonberg 185 

Fifth Grade, Kienb.6ck 186 

Osteoscope of Carl Beck; Spintermeter 186 

C. CARE OF THE TUBE T 186 

Connecting Leading Wires 187 

Blackening of the Tube 187 

Puncture and Explosion of Tube 188 



CONTENTS. xvii 

PAGE 

III. Fluoroscope and Accessories 189 

A. CONSTRUCTION OF THE FLUOROSCOPE 189 

B. SKIAGRAPHIC TABLE 190 

C. HOFFMAN'S MEASURING STAND AND FRAME 190 

D. TUBE-HOLDERS 191 

E. BOX-COVER FOR TUBE 191 

F. DIAPHRAGM AND COMPRESSION DIAPHRAGM 192 

IV. Selection and Installation of the X-Ray Apparatus 193 

A. SELECTION. Hospital, City, Country, Portable Outfits 193, 194 

B. INSTALLATION. Connections (Diagrams) 194-197 

C. POLARITY AND CONNECTION OF TUBE 197 

Advantages of Static Machine 198 

Disadvantages of Static Machine 198, 199 

Automatic Switch for X-ray Work 199 

CHAPTER II. 
THE PRINCIPLES OF TECHNIC. 

I. Fluoroscopy 200 

A. METHODS OF EXAMINATION 200 

(a) Screen and Fluoroscopic Examinations 200 

(b) Preparation of the Patient 201 

(c) Position of Tube 202 

(d) Position of the Patient 203 

(e) Size, Shape, and Intensity of Image on the Screen 203 

B. ADVANTAGES OF FLUOROSCOPY 203 

C. DISADVANTAGES OF FLUOROSCOPY 204 

II. Skiagraphy 204 

A. SYNONYMS, DEFINITION, AND NOMENCLATURE 204 

B. THE PATIENT 206 

History Taking 206 

Preparation of the Patient 206 

Position of Patient 206 

Immobilization of Part 207 

C. PLATES, THEIR PREPARATION, SIZE, AND PROTECTION 207 

Data on the Negative 208 

D. SELECTION AND USE OF THE CROOKES TUBE 205 

Position of the Tube 20s 

Form of the Ray-emitting Area of the Anti-cathode 209 

Direction of the Rays 209 

Anodal Distance of the Tube from the Plate 209 

E. FACTORS VARYING THE TIME OF EXPOSURE 210 

The Capacity of the Apparatus 210 

The Peculiarity of the Part to be Examined 210 

Quality of the Rays 210 

Intensifying Screens 210 

F. PREVENTION OF SECONDARY OR S AGNAC RAYS 210 

Lead Iris Diaphragm 211 



xviii CONTENTS. 

PAGE 

III. Photography 211 

Dark Room; Light 211 

Sensitive Plates and Films 212 

Care of the Plates 212 

A. DEVELOPERS: FORMULAS; VARIETY 212 

(a) Reducing 212 

(b) Preservative 213 

(c) Accelerating 213 

(d) Restraining 214 

Tropical Developer 214 

B. MODUS OPERANDI OF DEVELOPMENT 214 

Developing: Rapid; Slow Process (Tank) 216 

Fixing, Washing, Drying, and Hardening 217-219 

C. IMPROVEMENT OF THE NEGATIVE 219 

Intensification 219 

General and Local Reduction 220 

Causes and Prevention of Faulty Negatives: Fogging, Stains, 

Spots 221 

D. PRINTING (POSITIVE); TONING AND MOUNTING 221 

Dodging 222 

Ground-Glass Substitute 222 

Developing Papers 222 

Toning Process and Formula 223 

Printing and Mounting; Positives 223 

Transparencies and Lantern Slides 224 

IV. The Interpretation of the X-Ray Negatives 224 

What Constitute Satisfactory Negatives 224 

How to View the Negative 224, 225 

The Proper Light; Author's Examining Box 225, 226 

A. FOREIGN BODIES 226 

B. FRACTURES AND DISLOCATIONS 227 

C. DISEASES AND TUMORS OF THE BONES 227 

D. DISEASES OF THE SOFT STRUCTURES 228 

E. DISEASES OF THE THORACIC ORGANS 228-230 

F. ALIMENTARY SYSTEM 230 

G. GENITO-URINARY SYSTEM 230-232 

V. Stereo-Fluoroscopy and Skiagraphy 232 

A. HISTORY AND PRINCIPLES 232, 233 

B. STEREO-FLUOROSCOPY 233 

C. TECHNIC OF STEREO-SKIAGRAPHY 234-239 

D. METHODS OF VIEWING STEREO-SKIAGRAMS 239 

Wheatstone ' 239 

Brewster 239 

Plastography 240 

E. ADVANTAGES OF STEREO-SKIAGRAPHY 240 

Anatomy; Surgery 241 

CHROMO-STEREO-RONTGENOGRAMS 241 

PLASTIC RONTGENOGRAPHY . . 243 



CONTENTS. xix 

CHAPTER III. 
THE CLINICAL APPLICATIONS OF THE RONTGEN RAYS. 

PAOB 

I. The Uses of X-Rays in Anatomy and Physiology 246 

A. BLOOD-VESSELS AND RESPIRATORY TRACT 246 

B. BONES AND JOINTS 247, 248 

C. PHYSIOLOGY OF PHONATION 249, 250 

II. Diagnostic Value in Fractures and Dislocations and Callus Formation 250 

A. THE ADVANTAGES OF THE RONTGEN RAY METHOD IN THE DIFFERENTIA- 

TION OF COMPLICATED FRACTURES 251 

B. DISEASES AND TUMORS OF THE BONES AND JOINTS 252 

C. VALUE IN THE TREATMENT OF FRACTURES 253 

D. STUDY OF CALLUS FORMATION 253 

Duration and Varieties 253 

Perfect Apposition of Fragments 254 

Slight Overlapping 254 

False Joint 254 

Fractures with Extensive Displacements 254 

Structure of the Callus 254 

III. Fractures and Dislocations of the Upper Extremity 254 

HAND. Fluoroscopic Examination 254 

Skiagraphic Examination 255 

WRIST-JOINT. Fluoroscopic and Skiagraphic Examinations 255 

LOWER END OF RADIUS AND ULNA 255 

FOREARM 256 

ELBOW-JOINT. Fluoroscopic and Skiagraphic Examinations 257 

MIDDLE THIRD OF THE HUMERUS 258 

SHOULDER-JOINT. Fluoroscopic and Skiagraphic Examinations 258 

Dislocations 258, 259 

CLAVICLE. Skiagraphic Examination 259 

SCAPULA. Skiagraphic Examination 260 

FRACTURES OF THE SKULL. Skiagraphic Examination 260 

IV. Fractures and Dislocations of the Lower Extremity 260 

FOOT 260 

ANKLE 261 

LEG (MIDDLE THIRD) 262 

KNEE-JOINT; PATELLA 262 

FEMUR (MIDDLE AND LOWER THIRDS) 263 

HIP-JOINT 263 

THE Os INNOMINATA, SACRUM, AND COCCYX 264, 265 

THE SPINAL COLUMN 265 

RIBS AND STERNUM 266 

V. Diseases of the Osseous System 266 

A. PATHOLOGICAL CONDITIONS 267 

Acute and Chronic Periostitis and Osteomyelitis 267 

Tuberculosis of Bone 267 

Syphilis of Bone 267 

Hypertrophic Deforming Osteitis (Paget's Disease) 267 



xx CONTENTS. 

PAGE 

A. PATHOLOGICAL CONDITIONS. Continued. 

Leprosy 267 

Acromegaly 268 

Rickets 268 

Cretinism 268 

Osteomalacia 268 

Necrosis and Caries 268 

B. TUMORS OP THE BONES 268 

Sarcoma, Carcinoma, and Cysts 269 

C. DEFORMITIES OF BONES 269 

Congenital 269 

Exostoses 269 

Deformities of Intra-uterine Origin 269, 270 

Diseases and Deformities of the Spinal Column 270 

Torticollis 270 

Pott's Disease 270 

Amputation Stumps 270 

Resection of Joints 271 

Regeneration of Bone 271 

VI. Diseases and Tumors of the Soft Tissues 271 

Haematomata 271 

Abscesses 271 

Myomata and Fibromata 272 

Enchondromata; Lipomata; Sarcomata; Carcinomata 272 

Tumors of the Brain 272 

Reports of Cases 273, 274 

Calcareous Deposits in Glands 276 

VII. The Articular System 276 

A. DISEASES OF THE JOINTS 276 

Acute Arthritis 276 

Acute and Chronic Articular Rheumatism 276 

Gout 276 

Tuberculous Arthritis 277 

Coxalgia 277 

Coxa Vara 277 

Genu Valgum 278 

Genu Varum 278 

B. ARTHROPATHIES 278 

Tabes; Syringomyelia 278 

VIII. Foreign Bodies and their Localization 279 

A. MILITARY SURGERY 279 

Grseco-Turkish War 279 

Chitral Campaign 279 

Soudan 279 

Spanish-American War 280 

South Africa 280 

Russo-Japanese War 280 

B. VARIETIES OF FOREIGN BODIES 280 

Transparent; Translucent; Opaque 280 

Table of Permeability of Rontgen Rays 280 



CONTENTS. xxi 

PAGE 

C. FOREIGN BODIES IN THE DIGESTIVE, RESPIRATORY, AND GENITO-URI- 

NARY TRACTS 281 

(Esophagus 281 

Stomach 282 

Intestines 282 

Larynx, Trachea, and Bronchi 282 

Genito-Urinary Tract 282 

Foreign Bodies entering from Without 283 

D. THE X-RAYS IN OPHTHALMOLOGICAL SURGERY 283 

Foreign Bodies in the Eye 283 

Sweet's Method of Localization 284-289 

Davidson's Method 289-291 

Grossman's Method 291, 292 

Fox's Method 292 

E. VARIOUS METHODS OF LOCATING FOREIGN BODIES 293 

Screen Method 293 

Punctograph 293 

Henry's Method 294 

Barrel's Method 294 

Shenton's Method 295 

Harrison's Method 296 

Leonard's Double Focus Stereoscopic Method 296 

Triangulation Method 297 

Grashey's Method 297, 298, 299 

CHAPTER IV. 
APPLICATION OF THE X-RAYS IN DISEASES OF THE THORACIC ORGANS. 

I. Fluoroscopic Examinations 300 

Anterior and Posterior Views 300 

Lateral and Oblique Views 301 

Methods of Examination of the Lungs 301 

Normal Heart and Diaphragm 302 

Measurement of the Diaphragmatic Incursion 302 

Measurement of the Costal Angle 303 

Causes of Restriction of the Diaphragm 304 

Diseases of the Diaphragm 304 

Average Normal Excursion of Diaphragm; Width of Normal 

Heart 305 

II. Skiagraphic Examinations 305 

Various Positions of Patient 305 

Time of Exposure 306 

Instantaneous Rontgenography 307 

III. Clinical Applications 309 

A. DISEASES OF THE BRONCHI AND LUNGS 309 

Bronchitis; Bronchiectasis 309 

Asthma 310 

1 1 Emphysema 311 



xxii CONTENTS. 

PAGE 

A. DISEASES OF THE BRONCHI AND LUNGS Continued. 

Broncho-Pneumonia 311 

Pulmonary Tuberculosis 311-314 

Cavitation 314, 315 

Acute Miliary Tuberculosis 315 

Pneumonia 316 

Atelectasis 316 

Abscess and Gangrene 317 

B. DISEASES OF THE PLEURA 317 

Pleurisy with Effusion 317 

Empyema 318 

Pneumothorax; Hydro-pneumothorax and Pyo-pneumothorax, 319 

Subphrenic Abscess; Tumors of the Thorax 319 

Enlarged Glands 320 

IV. Applications of the X-Rays to the Circulatory System 320 

A. FLUOROSCOPIC EXAMINATION OF THE NORMAL HEART 320 

The Orthodiagraph 321 

B. SKIAGRAPHIC EXAMINATION OF THE HEART 324 

Telerontgenography 325 

Size and Measurement of the Heart; Cardiac Mobility 327 

Displacement '. 327 

Cardiac Atrophy, Hypertrophy, and Dilatation 329 

Examination of the Heart 330 

Pericarditis (Pericardial Effusion) 330 

Aortic Aneurism 331 

Dilatation of the Aorta; Displaced Aorta; Enlarged Glands. . . 333 

Neoplasms; Pulsating Empyema; Atheroma 33? 

CHAPTER V. 

APPLICATIONS OF THE X-RAYS IN DISEASES OF THE ABDOMINAL ORGANS. 

I. Alimentary System 334 

A. (ESOPHAGUS 334 

Stricture; Stenosis 335 

Diverticulum; Tumors 335 

B. STOMACH: SIZE, SHAPE, AND POSITION 335 

Examination by the Aid of Gaseous Distention 335 

Mechanical Method 335 

Bismuth Subnitrate Method 336 

Fluoroscopic and Skiagraphic Examinations of Stomach 336 

Time of Exposure : 337, 338 

Transillumination 339 

C. THE CLINICAL APPLICATION OF THE RAYS 340 

Behavior of the Stomach during Digestion 340 

Position of the Stomach 340 

Gastroptosis 341 

Stenosis of the Pyloric End 342 



OOOTENTS. xxiii 

PAGE 

D. INTESTINES 342 

Sounding and Radiography of the Large Intestine 342 

Obstruction 343 

Rectal Imperforation 343 

Abdominal New Growths 344 

E. LIVER 344 

Size and Location 344 

Biliary Calculi 344, 345 

F. PANCREAS 346 

G. SPLEEN 346 

II. The Genito-Urinary System 347 

A. ORDINARY METHODS; DIFFICULTIES 347, 348 

B. CALCULI: their Specific Gravity, Penetrability, and Density 348 

Hypertrophy; Atrophy 349 

Hydronephrosis and Pyonephrosis 349 

C. TECHNIC OF RENAL SKIAGRAPHY 350 

Preparation of Patient 350 

Literature of Renal Calculi 350-352 

Advantages and Defects of this Method 353 

D. URETERAL CALCULI 353 

Reports of Cases 353-357 

E. THE BLADDER 357 

Examination for Calculi 357 

Closure of the Bladder, as shown by X-Rays 358 

F. PROSTATIC CALCULI 358, 359 

Rontgenography of the Urinary Bladder after Oxygen Insuffla- 
tion 359 

Exploration of Fistulous Sinuses and Abscess Cavities by the 

Bismuth Emulsion Method 360 

CHAPTER VI. 
APPLICATION IN THE SPECIALTIES. 

I. Obstetrics and Gynaecology 362 

Pelvimetry 362 

Skiagraph of Fretus 365 

Skiagram of Gravid Uterus 366 

Neoplasms 367 

II. Rhinology, Laryngology, and Otology 367 

Abscess of the Antrum and of the Frontal Sinuses 368 

Foreign Bodies in the Larynx 369 

Ossification of the Laryngeal Cartilages 369 

Foreign Bodies in the Ear 369 

Abscess of the Mastoid Process 369 

CHAPTER VII. 
APPLICATION IN DENTISTRY. 

I. Apparatus Used 370 

II. Technic 370 

Intra-Oral 370 

Extra-Oral or Buccal; Tousey's Method 371 



xxiv CONTENTS. 

PAGE 

III. Clinical Applications 372 

Unerupted Teeth 372 

Necrosis of the Maxilla 372 

Ankylosis of the Inferior Maxillary Articulation 373 

Fracture of the Inferior Maxillary Bone 373 

Broken Instruments; Root-Canal Fillings; Abscess of the Antrum 373 

Alveolar Abscess; Orthodontia 373 

CHAPTER VIII. 
THE RONTGEN RAYS IN FORENSIC MEDICINE. 

I. Legal Status of the X-Rays 375 

A. ADMISSIBILITY IN VARIOUS STATES 375-377 

B. TECHNIC OF MEDICO-LEGAL SKIAGRAPHY 377, 378 

C. How THE SKIAGRAPHER SHOULD PREPARE FOR COURT 378-382 

II. The Physician's Responsibility in Cases of X-Ray Burn 382-387 

Medico-Legal Aspect of Sterility 387, 388 



PART III. 
RADIOTHERAPY, RADIUM, AND PHOTOTHERAPY. 



CHAPTER I. 

ACTION OF THE X-RAYS ON BACTERIA. 
Experiments of Numerous Operators 389-395 

CHAPTER II. 

HlSTOLOGICAL CHANGES INDUCED BY THE ACTION OF THE X-RAYS. 

I. X-Ray Dermatitis 395, 398 

A. CAUSES OF X-RAY DERMATITIS 398, 399 

B. CLASSIFICATION OF X-RAY DERMATITIS 399 

C. LATENT STAGE; FREQUENCY AND SUSCEPTIBILITY IN X-RAY DERMA- 

TITIS 401^404 

D. PATHOLOGICAL PHYSIOLOGY 404-406 

E. DURATION OF CHRONIC DERMATITIS 406 

F. PREVENTIVE MEASURES AGAINST X-RAY DERMATITIS 407, 408 

G. TREATMENT OF X-RAY DERMATITIS 408-412 

II. Remote and Indirect Action of the X-Rays 412 

STERILITY 412-414 

CHAPTER III. 

CHANGES INDUCED IN VARIOUS DISEASED TISSUES BY THE RONTGEN 

RAYS.. . 415-420 



CONTENTS. xxv 

CHAPTER IV. 

TECHNIC OF RONTGEN RAY THERAPY. 

PAGE 

I. Apparatus and Method of Treatment 420-422 

CEOOKES' TUBE 422 

PROTECTION OF HEALTHY PARTS 422^123 

POSITION OF THE TUBE; DISTANCE OF THE TUBE 424 

DURATION OF EACH EXPOSURE; FREQUENCY OF THE EXPOSURE 425 

FILTERS; THE DOSAGE 426 

II. Methods of Measuring X-Ray Dosage 427 

A. MEASUREMENT OF THE ELECTRIC CURRENTS 427 

The Current going to the Primary Coil 427 

Milliamperage of the Secondary Induced Current 427, 428 

Spintermeter 429 

B. THE PENETRATION METHOD 429 

The Radiochromometer of Benoist 429-431 

Skiameters and Penetrometers; Cryptoradiometer of Wehnelt . 431 

C. THE PHYSICO-CHEMICAL METHOD 431 

Chromoradiometer of Holzknecht 432 

Radiometer of Sabouraud and Noir6 432, 433 

Chromoradiometer of Bordier 433, 434 

Quantimeter of Kienbock 434 

New Radiometer of Freund 435 

Precipitation Test 436 

D. THE IONIZATION METHOD 436 

lonization of Confined Gases 436 

The Radio-active Standard of Phillips 437 

E. THE PHOTOMETRIC METHODS 438 

The Radiometer of Courtade 438 

The Guilleminot-Courtade Method 438 

The Fluorometer 438 

The Method of Contremoulins 439 

Selenium Photometer 439, 440 

Fluorescence of the Tube and the Appearance of the Electrodes 440 
The Thermometric Method 441 

III. Natural Fluorescence in the Human Organism and its Artificial Pro- 

duction 441 

APPLICATION IN DISEASE 442, 443 

Influence of Photodynamic Substances on the Action of X-Rays, 443 

CHAPTER V. 
THERAPEUTIC VALUE IN DISEASE. 

I. Cutaneous Affections 444 

LUPUS ERYTHEMATOSUS 444 

LUPUS VULGARIS 444, 445 

446 



xxvi CONTENTS. 

PAGE 

ALOPECIA AREATA; Parasitic Alopecia 447 

HYPERTRICHOSIS 447-449 

FAVUS AND TINEA TONSURANS 449-451 

ECZEMA 451. 452 

ACNE 452 

Acne Vulgaris 4."):; 

Acne Rosacea 453, 454 

SYCOSIS 454, 455 

PRURITUS ANI AND PRURITUS VULV^E 455 

XERODERMA PIGMENTOSUM 455 

PSORIASIS 456, 457 

SENILE LEG ULCERS; VARICOSE VEINS 457 

HYPERIDROSIS 45S 

KRAUROSIS VULV.E 458 

LEPROSY 459 

II. Malignant Growths 460 

A. EPITHELIOMA 460-464 

B. CARCINOMA 464, 465 

Cancer of the Breast 465-469 

Cancer of the Sternum; Cancer of the (Esophagus 469 

Cancer of the Larynx 470 

Cancer of the Stomach and Bowels 470 

Cancer of the Uterus 470, 471 

Therapeutic Action of the X-Rays in Cancer 471-473 

C. SARCOMA 473-477 

III. Constitutional Diseases 477 

A. TUBERCULOSIS 477-482 

B. LEUKEMIA 482-487 

IV. Miscellaneous Affections 487-497 

A. TRACHOMA 487-489 

B. KELOID 489, 490 

C. EXOPHTHALMIC GOITRE 490-492 

D. HYPERTROPHIED PROSTATE 492 

E. ANALGESIC ACTION OF THE RAYS 493-495 

Neuralgia 493 

F. EPILEPSY 495-497 

CHAPTER VI. 
RADIUM AND OTHER RADIO-ACTIVE SUBSTANCES. 

OCCURRENCE 498 

CHEMICAL AND PHOTOGRAPHIC EFFECTS 498-500 

PHYSICAL PROPERTIES OF RADIUM 500 

Penetration; Fluorescence and Luminosity 500 

THEORETICAL CONSIDERATIONS: CLASSIFICATION 501 

BIOLOGICAL EFFECTS 501 

Bactericidal Action 501 

Influence of Radium on Agglutination; Physiological Action . . 502 

Effects on the Nervous System; Effects on the Eye 502 



CONTENTS. xxvii 

PAGE 

RADIUM AND THORIUM AS THERAPEUTIC AGENTS 503 

Diseases of the Skin 503 

Mode of Retrogression of Cancer Metastases under Radium Rays, 504 

Reports of Various Radium Therapeutists 505-507 

Exophthalmic Goitre; Rabies; Nsevus 507 

Radio-active Treatment with Thorium 508 

Rheumatism 509 



CHAPTER VII. 
PHOTOTHERAPY. 

COMPOUND NATURE OP LIGHT 510, 511 

ACTION OF LIGHT ON PLANTS 511 

ACTION OF LIGHT ON BACTERIA 511, 512 

EFFECT OF LIGHT ON ANIMALS AND MAN 512 

THERAPEUTIC ACTION OF LIGHT; ITS USE AMONG THE ANCIENTS 513 

TREATMENT WITH SUNLIGHT 514 

TREATMENT WITH THE INCANDESCENT ELECTRIC LIGHT 514, 515 

TREATMENT WITH THE CONCENTRATED ARC LIGHT 515, 516 

THE DERMO OR IRON ELECTRODE LAMP 516 

THE COOPER-HEWITT MERCURY-VAPOR LAMP 516, 517 

KROMAYER'S QUARTZ MERCURY LAMP 517 

THE FINSEN OR RED-LIGHT TREATMENT OF SMALLPOX 518-521 

Conditions for Success by Finsen's Method 521 

BLUE LIGHT 521 

Blue Light as an Anaesthetic 522 

APPENDIX: 

TECHNIC OF RONTGEN RAY TREATMENT. . 523 



ILLUSTRATIONS 



FIG. PAGE 

Professor William Conrad Rontgen. Statue of Professor Rontgen on the 
Potsdam Bridge, Berlin Frontispiece 

1. Electrical units illustrated by means of the hydraulic analogy (Hedley) .... 7 

2. Connection of battery cells in " series " 12 

3. Connection of the cells in " parallel " 12 

4. Connection of the cells in " groups " 13 

5. Diagrammatic view of the inner construction of a storage cell (American 

Battery Co.) 13 

6. Diagrammatic view illustrating the charging of a battery by the ammeter 

and volt-meter 15 

7. Diagrammatic view illustrating the charging of a battery by a bank of lamps 16 

8. Diagrammatic view illustrating the principles of influence and accumulation 

of static or influence machines 19 

9. Diagrammatic illustration of the theory of action of a Wimshurst influence 

machine 20 

10. Wimshurst influence machine 21 

11. Toepler-Holtz influence machine 22 

12. Static-disk electrode with insulated points 25 

13. Static massage electrodes for wet applications 25 

14. Universal hard-rubber handle for holding electrodes 25 

15. Insulated hook for holding conducting cord 25 

16. Pole changer of Betz 28 

17. Static breeze, concentrated brush discharge, or spray facing 28 

18. Static negative insulation or static bath facing 28 

19. Direct spark facing 28 . 

20. Indirect spark facing 29 

21. Friction-spark treatment facing 30 

22. Static induced current facing 31 

23. Galvanic cell 34 

24. Bunsen cell (double fluid) 35 

25. Wall cabinet for galvanic, faradic, and sinusoidal currents 37 

26. Deprez-D' Arson val galvanometer (milliamperemeter) 39 

27. Galvanic, faradic, cautery, and diagnostic lamp battery 41 

28. Medical induction coil 44 

29. Galvanic and faradic lamp controller 45 

30. Peterson's cataphoric electrode facing 48 

30A. Sectional view of the same facing 48 

30B. Three varieties of cataphoric electrodes facing 48 

30C. Martin's cataphoric electrode facing 48 

31. Massey's method with zinc-mercury cataphoresis 48 

32. Diagrammatic scheme of the passage of ions (Zimmern) 49 

33. Penetration of ions through the integument (Leduc's experiment) 51 

34. The four-celled battery of Schn6e 54 

xxix 



xxx ILLUSTRATIONS. 

FIG. PAGE 

35. Diagrammatic view of the direction of current as is illustrated in SchneVs 

four-celled battery 59 

36. Motor points of the arm 59 

37. Motor points of the forearm and hand 60 

38. Motor points of the arm (front view) 60 

39. Motor points of the forearm and hand (front view) 60 

40. Motor points of the thigh 61 

41. Motor points of the leg and foot 61 

42. Motor points of the thigh and leg (posterior view) 62 

43. Motor points of the leg and foot (inner side) 62 

44. Motor points of the head and neck 63 

45. Motor points of the chest and abdomen 63 

46. Interrupting needle holder for electrolysis 80 

47. Roller electrode with insulated points for muscular faradization 83 

48. Double rectal bulb electrode 91 

49. Shoemaker's prostatic electrolyzer 94 

50. Vesical electrode for hydro-electric application to the female bladder 103 

51. Goelet's intra-uterine electrode 103 

52. Ozone inhalation facing 108 

53. Curved sponge electrode for application to throat 109 

54. Electrode for hydro-electric application, post-nasal and pharyngeal 109 

55. Double sponge-tipped ear electrode Ill 

56. Adjustable eye electrode, for one or both eyes 116 

57. Oscillatory nature of the Leyden-jar discharge 119 

58. Morton's "static-induced current" high-frequency apparatus 120 

59. D'Arsonval high-frequency apparatus 121 

60. The Tesla transformer 122 

61. Diagram of the Oudin resonator facing 122 

62. The Oudin resonator and Tesla coil, with electrode facing 122 

63. Glass electrodes facing 123 

64. Piffard's glass electrode 124 

65. Morton's cataphoric electrode 124 

66. Auto-condensation 128 

66A. Treatment by auto-conduction facing 128 

67. Treatment by the effluviation method facing 128 

67 A. Diagrammatic view of Keating-Hart's method of f ulguration facing 138 

67B. Keating-Hart's electrodes for fulguration facing 138 

68. Diagram illustrating the principles of induction (after Donath) 154 

69. Self-starting interrupter facing 156 

70. Diagrammatic view of self-starting interrupter (Rontgen Manufacturing 

Co.) facing 156 

71. Mercury interrupter 157 

72. Davidson's interrupter facing 158 

73. Johnston's mercury interrupter facing 158 

74. Wehnelt interrupter 159 

75. Simon interrupter 160 

76. Friedlander electrolytic interrupter 161 

77. The Tesla oscillator 164 

78. Outer view of the same 164 

79. Lines of force in the older coils 166 

80 Lines of force in Kinraide's coil .. 166 



ILLUSTEATIOXS. xxxi 

FIG. PAGE 

81. Kinraide's diagram of two coils side by side 167 

81 A. Scheidel- Western coil facing 170 

81B. Diagrammatic view of Snook-Rontgen apparatus facing 170 

81C. The Snook-Rontgen transformer facing 170 

81D. Diagram of the current in a tube supplied by an X-ray apparatus without 

interrupter 173 

81E. Diagram of the current in a tube supplied by an induction coil 173 

81F. Diagrammatic view of an X-ray apparatus without an interrupter 174 

81G. 100-plate static machine of Wagner facing 174 

82, 83. Discharge passing through low-vacuum tubes (Bouchard) 176 

84. Cathode rays (Bouchard) 176 

85. Deflection of the cathode rays (Bouchard) 176 

86. Illustration of the effect of one cathode and several anodes under different 

degrees of vacuum (Bouchard) 177 

87. Illustration of one of the phenomena in high vacua, the rectilinear propaga- 

tion of the cathode rays (Bouchard) 177 

88. Essential features of an X-ray tube 178 

89. Queen's self-regulating tube 181 

90. Muller's regulation tube 182 

91. Monopol tube 183 

92. Osmosis regulating tube of Gundelach 184 

93. Self-regulating X-ray tube, operating properly facing 184 

94. Self-regulating X-ray tube, current running in wrong direction facing 186 

95. Villard's ventril tube 188 

96. Self-regulating X-ray tube, low vacuum facing 188 

97. Self-regulating X-ray tube, punctured or cracked, bulb partially filled with 

air facing 190 

98. Ordinary diaphragm 193 

99. Tubular or compression diaphragm (Donath) 193 

100. Author's table and tube-holder 195 

101. Diagrammatic view of the installation of the "jumbo " coil and its connections 

with the variable primary coil, as used by the author at the Philadelphia 

Hospital 196 

102. Author's office outfit 197 

103. Polarity as determined by the appearance of the spark 198 

103A. Wagner's Automatic switch facing 198 

103B. Time Switch facing 199 

104. Detachable fluoroscope and screen 201 

105. A study in shadow distortions (fluoroscopic or skiagraphic) with correspond- 

ing density difference 202 

106. Envelo developer (Lyon Camera Co.) facing 216 

107. Automatic tray-rocker (Rontgen Manufacturing Co.) facing 216 

108. Author's washing tank 218 

109. Author's negative-viewing box 226 

110. Principles of Brewster's refracting stereoscope 233 

111. Principles of Wheatstone's reflecting stereoscope 233 

112. Technic of stereo-skiagraphy, and viewing by reflection and refraction 235 

113. Author's plate-changing box 236 

114. Wheatstone's reflecting stereoscope, as modified by Weigel facing 240 

115. Prism stereoscope of Walter facing 240 

116. Stereo-skiagrams of Colles's fracture facing 240 



xxxii ILLUSTKATIOm 

FIO. p AQB 

116A. Author's method of plastic Rontgenography 245 

i!6B. Congenital dislocation of the head of the left femur facing 244 

116C. Plastic Rontgenogram of the above facing 244 

116D. Wrist-joint (antero-posterior view) facing 254 

116E. Antero-posterior views of both wrist-joints facing 254 

117. Inward dislocation of the first phalanx of the thumb facing 256 

118. The normal hand, taken with high- vacuum tube facing 256 

119. Fracture of the scaphoid facing 256 

120. Colles's fracture (antero-posterior view) facing 256 

121. Colles's fracture (lateral view) facing 256 

122. Fracture of the styloid process of the ulna (supine position) facing 256 

123. The same (prone position) facing 256 

124. Typical Colles's fracture facing 256 

124A. Elbow-joint (lateral view) facing 256 

124B. Elbow-joint (antero-posterior view) facing 256 

124C. Wrist-joint (lateral view) facing 257 

124D. Shoulder-joint (dorsal decubitus view) facing 258 

124E. Shoulder-joint (erect dorsal view) facing 258 

124F. Shoulder-joint (posterior-anterior view) facing 258 

125. Green-stick fracture of the ulna facing 260 

126. Fracture of the neck of the radius facing 260 

127. Epiphyseal separation and displacement of the lower end of the humerus 

facing 260 

128. Fracture of the ulna and displacement of the head of the radius facing 260 

129. Supracondyloid fracture of the humerus facing 260 

130. Fracture of part of inner epicondyle, after forcible reduction facing 260 

131. Detachment of a portion of the external condyle of the humerus (antero- 

posterior view) facing 260 

132. The same, in the lateral view facing 260 

133. Detachment of the supinator longus muscle facing 260 

134. Epiphysitis of the humeral head facing 260 

135. The corresponding normal side facing 260 

136. Subluxation of the shoulder-joint facing 260 

137. Fracture of the acromion process facing 260 

138. Fracture of the acromial end of the clavicle facing 260 

139. Fracture of the metatarsal bones facing 260 

139A. Feet (dorsal view) facing 260 

139B. Ankle-joint (lateral view) facing 260 

139C. Ankle-joint (antero-posterior view) facing 260 

139D. Knee-joint (lateral view) facing 260 

139E. Knee-joint (antero-posterior view) facing 262 

139F. Patella (posterior-anterior view) facing 262 

139G. Hip-joint (antero-posterior view) facing 262 

139H. Both hips (antero-posterior view) facing 262 

140. Fracture of the middle of the fourth metatarsal bone facing 264 

141. Pott's fracture facing 264 

142. Fracture of tibia and fibula, taken at an angle between the antero-posterior 

and lateral positions facing 264 

143. The same, in the lateral view facing 264 

144. Fracture of the anterior portion of the patella facing 264 

145. Detachment of the tubercle of the tibia facing 264 



ILLUSTRATIONS. xxxiii 

FIQ. PAGE 

146. Incomplete inter-trochanteric fracture facing 264 

147. Congenital dislocation of the head of the left femur facing 264 

148. Congenital dislocation of both hips facing 264 

149. Pathological dislocation of left hip in a child facing 264 

150. A case of probable infantile palsy facing 264 

150A. Cervical vertebrae (lateral view) facing 264 

150B. Cervical vertebra (antero-posterior view) facing 264 

151. Chronic osteitis with eburnation facing 268 

152. Osteitis of the index finger facing 268 

153. Tuberculous osteitis facing 268 

154. Syphilitic osteitis of the radius facing 268 

155. Necrosis of the os calcis facing 268 

156. Supernumerary thumb facing 268 

157. Congenital absence of the ulna and two fingers facing 269 

158. Congenital multiple exostoses facing 269 

159. Delayed ossification of the epiphyses facing 270 

160. Author's head rest 272 

161. Tuberculous arthritis of the knee-joint facing 278 

162. Coxa vara facing 278 

163. Arthropathies in the knee-joint facing 278 

164. Penny in the oesophagus facing 279 

165. Principles of the method of localization (Sweet) 285 

166. Indicating apparatus secured to the side of the head (Sweet) 286 

167. Outline drawing of radiograph, tube above the plane of indicators 287 

168. Outline drawing of radiograph, tube below the plane of indicators 287 

169. Sweet's chart for plotting location of foreign bodies in the eye 288 

170. Mackenzie Davidson's localizer 289 

171. Fox's localizer facing 292 

172. The right-angle method of localization \ . 293 

173. " T " scale used in the triangulation method 298 

174. Scheme of application of the " T " scale 298 

175. Orthodiagraphic localizer of Grashey 299 

176. Diagrammatic view of the same 299 

176A. Lungs (dorsal decubitus) facing 304 

177. Tuberculosis of the right lung (posterior view) facing 314 

178. Tuberculosis of the right lung (anterior view) facing 315 

179. Moritz' orthodiagraph (horizontal position) facing 320 

180. Moritz' orthodiagraph (vertical position) facing 320 

181. Levy-Dorn's orthodiagraph for the standing position 323 

182. Levy-Dorn's orthodiagraph for use in the recumbent posture 324 

182 A. Lungs and heart (erect dorsal position) facing 324 

183. Author's table for skiagraphing the heart and lungs facing 324 

184. The same when used in the sitting position facing 324 

185. Aneurism of the descending aorta facing 332 

186. Tracing of the same facing 332 

187. Dilatation of the heart, with aneurism of the aorta facing 332 

188. Atheroma of the femoral artery facing 332 

188A. Stricture of oesophagus (right oblique position) facing 334 

188B. Compression diaphragm for localized strictures of oesophagus . . . .facing 334 

188C. Lungs, heart, and aorta (vertical view) facing 334 

188D. Strictures of the oesophagus and aorta (antero-oblique view) facing 334 



xxxiv ILLUSTRATIONS. 

FIG. PAGE 

189. A case of gastroptosis (bismuth emulsion method) facing 342 

189A. Stomach and intestines facing 344 

189B. Liver (ventral view) facing 344 

189C. Kidney (dorsal view) facing 352 

189D. Vesicse (dorsal view) facing 352 

190. Reid's apparatus for renal skiagraphy 354 

191. Clock arrangement and break of the same 355 

192. Compression diaphragm of Albers-Schonberg (Kny-Scheerer Co.) 356 

193. The same, postero-anterior view (Kny-Scheerer Co.) 357 

194. Calculus in the pelvis of the right kidney facing 358 

195. Vesical calculus facing 359 

196. Varnier's arrangement for radiography 364 

197. Author's head rest for stereoscopic work 366 

197 A. Skull (sagittal view) facing 366 

197B. Skull (occipito-frontal view) facing 366 

198. Author's head rest for skiagraphing diseases of the frontal sinuses 368 

199. Tumor in the trachea facing 368 

199A. Dental Rontgenography facing 372 

199B. Extra-oral method facing 372 

200. Extra-oral method in dental skiagraphy facing 372 

201. Unerupted teeth facing 372 

202. Unerupted upper cuspid tooth facing 372 

203. Delayed eruption of the upper cuspid tooth facing 372 

204. Delayed eruption of the upper cuspid tooth with the temporary teeth in situ 

facing 372 

205. Delayed second bicuspid, right side of lower jaw facing 372 

206. Delayed second bicuspid, left side of lower jaw facing 372 

207. Phosphorous necrosis of the inferior maxilla facing 373 

208. Chronic alveolar abscess of the right central incisor tooth facing 373 

209. Author's hands, showing result of chronic X-ray dermatitis facing 400 

209A. Author's hands. Photograph taken 1899 facing 400 

209B. Author's hands. Photograph taken January 29, 1900 facing 400 

209C. Author's hands. Photograph taken April 1, 1900 facing 400 

209D. Author's hands. Photograph taken September 21, 1909 facing 400 

210. Author's scheme for the operator's protection 408 

210A. Diameter of diaphragms facing 420 

211. Piffard treatment tube 421 

212. The bi-cathode tube of Koch of Dresden 421 

213. The Kny-Scheerer tube 421 

214. Rosenthal's tube for therapeusis 422 

215. Connection of the tube and Villard valve with the oscilloscope 423 

216. Benoist's radiochromometer 430 

217. The improved Benoist radiochromometer as modified by Pfahler (Rontgen 

Manufacturing Co.) '. facing 430 

218. The same, with its parts connected (Rontgen Manufacturing Co.) facing 430 

219. The skiameter facing 430 

220. Crypto-radiometer of Wehnelt 431 

221. Kienbock's quantimeter 435 

222. Profile and full view of a patient with acne rosacea facing 456 

223. The same, after fifty irradiations facing 456 



ILLUSTRATIONS, xxxv 

FIG. PA.QB 

224. Epithelioma of the nose, before irradiation facing 456 

225. The same, after irradiation facing 456 

226. Epithelioma of fifteen years' standing, treated by irradiation, and in which 

radium therapy was employed as a control test facing 456 

227. Epithelioma of the dorsum of the hand, before irradiation facing 457 

228. The same, after irradiation facing 457 

228A. Method of treating a small epithelioma facing 464 

228B. Method of treating carcinoma of the breast facing 464 

228C. Method of treating affections of the cervical glands facing 464 

229. Tubes and rubber tube shields for therapy of the body cavities (R. V. Wag- 

ner Co.) 471 

230. Pennington's treatment [cavity] tube (R. V. Wagner Co.) 472 

231. Cavity tube applied (R. V. Wagner Co.) 472 

232. Sarcoma of the leg facing 476 

233. Skiagraph of the same facing 476 

234. Tuberculosis of the skin facing 488 

235. The same, after irradiation facing 488 

236. 237, 238. Groups of patients irradiated for epilepsy facing 489 

239. Hartigan's radium applicator 508 

240. Shober's radiode 509 

241. Solar spectrum, showing the scheme of wave lengths of different radiations. 510 

242. Cabinet for the treatment of disease by the employment of incandescent 

lights (Kny-Scheerer Co.) facing 514 

243. The Finsen method of treatment facing 515 

244. The dermo or iron electrode lamp 516 

244A. Kromayer's quartz mercury lamp facing 516 

245. Photograph of the late Professor Niels R. Finsen facing 518 

Rontgen ray treatment chart facing 526 



INTRODUCTION 



HISTORICAL SKETCH OF THE RISE OF ELECTRICITY 

IN the remotest periods of the world's history, when legend, myth, 
and fact were inseparably connected, the phenomena of electricity were 
regarded as symbolic of some special deity and formed the basis of a na- 
tional faith. The philosophers of Greece would bow in veneration at the 
sound of the thunderbolt, and in Rome the ominous herald of the storm 
would silence the orator in the Forum. Indeed, to enumerate the mean- 
ings and the attributes ascribed to the lightning flash and to the reverber- 
ating thunder would be to rewrite a lengthy and absorbing chapter from 
the pages of mythology. 

But in the midst of all this myth and superstition, this era of the 
legendary period, arose Thales of Miletus, whose profound knowledge 
of science and metaphysics had challenged the admiration of the famous 
Pho3niciau voyagers. These intrepid navigators were accustomed to 
sailing the straits of Hercules in order to reach the Baltic Sea, and from 
its desolate waters they would seize a delicate substance, fair in color, 
and beautiful in transparency. To Thales this strange creation of nature 
had mysterious properties. He named this precious find electron or am- 
ber, and he blazed the way for future knowledge in discovering that when 
electron was rubbed it possessed the property of attracting to itself vari- 
ous light articles. Three hundred years later Theophrastus enlarged 
upon the teaching of Thales and conferred the name of " animated gem" 
upon this beautiful product of the northern seas. Pliny followed with 
other learned dissertations ; and thus through ages the mysterious electron 
confounded the minds of philosophers, never once intimating that the 
secrets hidden in its delicate transparent substance were the secrets of 
Indra, the Jupiter of the Hindoos, or the terrible weapon of Jupiter 
Touans defiantly passing over suppliant Rome. Centuries passed. King- 
doms arose and nations disappeared, but the studies of Thales were never 
forgotten. Not till the dawn of the sixteenth century was the subject 
again brought forward upon a scientific basis. In 1590 Gilbert's work 
"De Magnete," having for its keynote the words: " Magnus inagnes 
ipse est globus terrestris," appeared in England, and the discoveries 
made by this new champion confused and terrified its readers. The super- 
natural seemed to envelop its pages ; the printed words breathed of the 
spiritual. Sparks and flames, shocks and strange sensations, pranced and 



xxxviii INTRODUCTION. 

teased the hands and bodies of hundreds of experimenters, and the masses 
of the people were almost unanimous in declaring that electron was in- 
vested with a soul. Although Physician in Ordinary to Queen Eliza- 
beth, Gilbert did not attempt to apply the knowledge thus gained to 
medicine. His friend, the poet Dryden, immortalized him in the follow- 
ing lines : 

"Gilbert shall live till lodestones cease to draw 
Or British fleets the boundless ocean awe." 

Such was the birth of the science of electricity. 

But the magnificent generalization made by Gilbert was but the 
initial step ; the scientifically inquisitive Otto von Guericke of Magde- 
burg quite promptly gave to the world a machine for generating elec- 
tricity, as useful at that period as was his indispensable air-pump. It 
remained, however, for Stephen Gray, in 1730, to disclose the secrets so 
deeply hidden in this mysterious substance, and it was he who ex- 
pounded the leading principles of the science of electricity. Amazed at 
the wondrous achievements attained by these later philosophers, Du Fay 
and Nollet in France assiduously applied themselves to a study of elec- 
trical phenomena. Du Fay suspended himself by a silken cord, and was 
then filled with electricity by Nollet ; he presented his hand to his com- 
panion, when a brilliant spark shot from hand to hand, a phenomenon 
that completely baffled the minds of both these scientists. 

Shortly after this the whole of Europe was awe-struck by the inven- 
tion of the Leydeu jar. Professor Musscheubroek received its first full 
discharge, and he wrote to Reaumur that he would not suffer a second 
such shock for the whole kingdom of France. Seizing upon this famous 
discovery, Franklin in America invented a battery of jars capable of 
giving shocks quite analogous to the terrifying powers of the thunder- 
bolt. It was Franklin's contention that the electricity of the earth and air 
was one, and it was this positive conviction that awakened the derision 
and evoked most painful sarcasm from the Royal Society of London. Not 
dismayed by this adverse criticism, the persistent American philosopher 
constructed a silken kite containing an iron point. Attached to the kite 
was a hemp string ending in a silken cord ; to the latter was hung an iron 
key. He selected a rainy day in June, 1752, for the experiment. Sta- 
tioning himself on what is now known as Ridge Avenue and Green 
Street, in Philadelphia, Franklin flew his curious apparatus to the 
breeze. Suddenly the falling rain made the hemp string an excellent 
conductor, the fibres were stirred as by a strange impulse ; he applied his 
hand to the key and at once drew sparks from its sides. He felt that he 
had triumphed : he had seized the vagrant lightning of the storm ! The 
Royal Society of London realized that a mighty scientific achievement 
had been wrought, and made him a member and awarded him their 



INTRODUCTION. xxxix 

greatest .prize, and he was signally honored in Germany, France, and 
Russia. 

During the eighteenth century, the science of electricity became one 
of the most important and interesting branches of knowledge. In 1790 
Galvani, through the convulsive movements of a dead frog, hanging from 
an iron balcony, brought forward his great discovery of galvanism. The 
immortal Volta improved upon Galvaui's teachings. With the intro- 
duction of the voltaic pile, in 1800, his fame spread world-wide, by later 
modifications he formed the beautiful "La Couronne de Tasses," the 
model by which to-day we flash our messages through the fathomless 
oceans. It was more than one hundred years after Gilbert's time, that 
electricity was first brought into use as a curative agent. De Haen 
(1745), Jallabert (1748), and Abbe Nollet (1749) were the first to employ 
static electricity in medicine. In 1758 Benjamin Franklin tried the 
action of the electric current on a number of paralytics. In 1759 the 
Reverend John Wesley, the famous divine, published a treatise entitled 
The Desideratum, or Electricity made Plain and Useful, by a Lover of Man- 
kind and Common Sense. The first records of electrical treatment at a 
London hospital are found in the year 1767, when a static machine was 
installed at the Middlesex Hospital, and in 1777 another was placed in 
St. Bartholomew's Hospital. At St. Thomas's Hospital the subject was 
systematically pursued by Mr. John Birch, the surgeon ; and in 1799 
he contributed an essay of fifty pages on medical electricity to John 
Adams's book, An Essay on Electricity. The nineteenth century has 
seen the fruits of these great labors practically applied. To enumerate 
even a tithe of the marvellous discoveries and inventions that form 
part of our conveniences, of our necessities, of integral parts of our every- 
day lives, would be merely to repeat an oft-told story a story of the 
great triumphs of human achievement. 



ELECTRICITY AS A P4RT OF THE MEDICAL CURRICULUM 

It has been estimated that about 12,000 physicians are constantly 
using some form of electricity in their daily practice. The question 
naturally arises, Why doesn't the subject of medical electricity form part 
of the college curriculum'? Without some theoretical and practical 
knowledge of the science, how can the physician hope to apply a current 
intelligently or know when its application is advantageous 1 ? Is not this 
ignorance of its principles and practical workings responsible for its being 
classed in the charlatan's armamentarium and its administrator desig- 
nated a quack f To understand medical electricity the tyro must begin 
in the laboratory. He must there study the physics of electricity and 
magnetism ; he must study electrical appliances for creating energy. 



xl INTKODUCTION. 

Besides these things he should diligently inquire as to the resistances 
encountered in the human body, the electrolysis resulting in living tissues, 
the range of voltage, etc. He needs to be trained especially in what may 
be termed the physiological action of the various currents and their 
therapeutic values. Indeed, if but one hour daily for a single term be 
devoted to the study of the mechanism of the apparatus, to the connection 
of the wires, the nature of the current, etc., and a corresponding limited 
number of hours be devoted in a succeeding term to the therapeutic 
application of the science, it is more than likely that a correct apprecia- 
tion of the study will be meted out to it, and the professed specialists 
who are now duping the unwary would be forced to retire ignominiously 
from the field. 



PRACTICAL 
ELECTRO-THERAPEUTICS 



PART I 
ELECTRO-THERAPEUTICS 



CHAPTER I 

THE ELEMENTABY PBINCIPLES OF ELECTEICITY AND 

MAGNETISM. 

IN the following paragraphs an effort has been made to present, in a 
space succinct yet commensurate with the importance of the subject, the 
underlying principles of electricity and magnetism, embracing the more 
usual terms, tables of units, sources of energy, and the fundamentals of 
the science necessary to an understanding of its application to medicine 
and surgery. Clearness of expression has been aimed at rather than a 
detailed scientific and mathematical exposition of every term employed. 
Those interested in a more elaborate study of these principles are referred 
to the standard works on natural philosophy and electricity. 

I. Nature and Properties of Magnetism. 

The nature of magnetism is more or less closely allied to that of elec- 
tricity. The term "magnet" is supposed to originate from the Greek 
word " Magnesia," a principality of ancient Greece, where deposits of 
magnetite were first discovered. Chemically this is known as magnetic 
iron ore (Fe 3 O 4 ). 

Magnets are of two kinds : 

(a) Natural, 

(b) Artificial. 

Experiments have demonstrated that, when steel bars are applied to 
lodestones or other magnets, they become magnetized, and the original 
magnet suffers no loss of magnetic property. Magnets made in this 
manner are called " artificial magnets." The original lodestones, from 
their inherent magnetic properties, are designated " natural magnets." 
Chemically the substance is known as " magnetite." 

5 



C ELECTRO-THERAPEUTICS. 

Magnetism may be temporary or permanent. Temporary magnetism 
is magnetism remaining only for a short time, as in soft iron. 

Permanent magnetism, as the name indicates, permanently resides 
in the magnet, as in steel. 

ELECTRO-MAGNETS. 

When a bar of soft iron has wound around it a coil of wire for the 
purpose of establishing a magnetic field, we obtain an electro-magnet. 
Soft iron is almost universally employed in the manufacture of electro- 
magnets. The use of hard steel with a similar strength of current yields 
far less magnetic force. 

II. Nature and Properties of Electricity. 

Electricity (derived from the Greek iJAexr/>x, amber) is the term 
applied to a certain invisible agent known to us only through its peculiar 
behavior. The early scientists held that electricity was a fluid ; later ex- 
periments tended to show that it behaved like an incompressible liquid, 
and in other ways resembled a gas highly attenuated and without weight. 
In the light of present knowledge, the fluid theories have been abandoned, 
and it is now generally accepted that the peculiar phenomena are the re- 
sult of some strain or other action in the ether, the latter being supposedly 
a fluid medium that exists in all parts of the universe in gases, solids, 
and liquids. 

A. THEORY OF POTENTIAL. 

The laws which concern the magnitude and measurement of electrical 
quantities are very difficult to explain. That branch of electrical science 
dealing with the measurements of electrical charges is called electro-statics. 
Many of the less complicated electrical phenomena may be conveniently 
illustrated by the action of fluids, though it must be remembered that 
such comparisons are only relative, and introduced to facilitate the easy 
mastering of electricity. Electrical potential, or electro-motive force (writ- 
ten thus E. M. F. ), is that property possessed by a body by means of 
which an electric current is enabled to pass from it, through some 
other medium, into another body. In order to simplify the theory of 
potential, it is essential to notice the elementary laws governing electrical 
force. 

Hydraulic Analogy. In order to simplify the term "potential," 
let us assume the following analogy between electricity and water. 
Let us suppose two reservoirs (both partly filled with water) at different 
levels and connected with each other by means of tubing. Evidently the 
-water in the reservoir placed at the higher level will flow through the 
pipe into the lower reservoir. The flow is due to difference in levels 



ELECTRICITY AND MAGNETISM. 7 

producing pressure (or motive force), measured by the difference in alti- 
tude (or potential) between the water contained in the two reservoirs. 
When the two reservoirs are placed at the same level, no difference in 
pressure will exist ; hence, no water will flow from the one reservoir to 
the other. If we substitute the word " potential" for "level," we then 
employ the common electrical term. 

Imagine two charged bodies to be connected with each other by wire ; 
a flow of current takes place from the positive to the negative charged 
body ; this is possible because of a difference in the potential in the two 
bodies. Allowing that the positive charged body is at a higher potential 
(or level) than the one charged negatively, we must state that the flow of 



IV&. 



r\ATE.OF FUOW: CUFWEKT \ ANVP. 



VYof\K DONE. 1 JouUE. 
I\ATE AT WHICH VYOUK 
IS DONE.1 WMT1 




FIG. 1. Electrical units illustrated by means of the hydraulic analogy. (Hedley.) 

current results from the difference in the potentials, thus creating an elec- 
trical pressure or electro-motive force. The fact that there is a flow of 
current from a higher to a lower potential must not be overlooked. From 
the foregoing remarks it may be assumed that no flow of current takes 
place between the bodies when they are at equal potentials. Whenever 
a stream of water falls from a higher to a lower level, it will perform a 
certain amount of work in its course downward, i. e., it has acquired a 
certain amount of potential force, and, besides, the difference of level can- 
not be restored without expending a certain amount of work. For every 
pound of water that is lifted through a difference of level equal to a foot, 
one foot-pound of work is done, no matter what the shape of the path 
may be by which the elevation of the water to a higher level is accom- 
plished. Likewise, electricity cannot be transferred from one body to 



8 ELECTRO-THERAPEUTICS. 

another at a higher potential without requiring a certain amount of work 
to be accomplished. The term potential, though relative, must be 
considered as meaning a force or power to do work. For instance, if we 
lift a one-pound body five feet high against the force of gravity, the 
weight of the pound-body in turn can accomplish five foot-pounds of 
work in falling to the ground. In the strictest sense of the term, poten- 
tials are relative ; hence it is always the difference of potential with 
which we are dealing. 

B. UNITS OF ELECTRICAL MEASUREMENT. 

C. G. S. System. Electricians have universally agreed to adopt a 
system of measurement based upon three fundamental units : namely, 
the centimeter, the unit of length ; the gramme, the unit of weight or 
mass ; and the second, the unit of time. All other units are derived 
from these three, and are known as derived units, one of the most impor- 
tant of these being the unit of force, called the dyne. The dyne is that 
force which when acting for one second of time on a mass of one gramme 
conveys to it a velocity of one centimeter per second. 

(a) Electro-static Units. (1) The unit of electro-static quantity is 
that quantity of electricity which, when placed at a distance of one centi- 
meter (in the air) from a similar and equal quantity, repels it with a 
force equal to one dyne. 

(2) The unit of electro-static potential is equal to the unit of work 
done in moving a unit of positive electricity against the electric forces. 

(3) The electro-static unit of difference of potential is that difference 
existing between two points when it requires the expenditure of one erg 
of work to bring a positive unit of electricity from one point to the other 
against the electric force. 

(4) The electro-static unit of capacity is that conductor which requires 
a charge of one unit of electricity to bring it up to unit potential. 

(5) By electro-motive intensity is meant the electric force of intensity 
of an electric fluid at any point, being measured by the force which it 
exerts on a unit charge placed at that point. 

(b) Magnetic Units. (1) The unit magnetic pole is one of such a 
strength that when placed at a distance of one centimeter (in the air) 
from a similar pole of equal strength, repels it with a force of one dyne. 

(2) Magnetic potential is measured by. the amount of work done in 
moving a unit magnetic pole against the magnetic forces. 

(3) Unit difference of magnetic potential exists between two points 
when it requires the expenditure of one erg of work to bring a unit mag- 
netic pole from one point to the other against the magnetic forces 
magneto- motive force being measured in the same units as difference of 
magnetic potential. 



ELECTEICITY AND MAGNETISM. 9 

(4) The intensity of magnetic field is measured by the force it exerts 
upon a unit magnetic pole ; hence, 

(5) Unit intensity of field is that intensity of a field which acts on a 
unit pole with a force of one dyne, the term gauss having been proposed 
for this unit. 

(6) Magnetic flux, or total induction of magnetic lines, is equal to the 
intensity of field multiplied by area its unit being equal to one magnetic 
line. 

(7) Magnetic reluctance is the ratio of magneto-motive force to mag- 
netic flux. 

(c) Electro-magnetic or" Absolute " C. G. S. Units. The pre- 
ceding magnetic units give rise to the following set of electrical units, in 
which the strength of currents, etc., is expressed in magnetic measure, 
according to the centimeter-gramme-secoud system : 

(a') A current has a unit of strength when one centimeter length of 
its circuit bent into an arc of one centimeter radius exerts a force of one 
dyne of a unit magnet- pole placed at the centre. 

(&') Unit of difference of potential exists between two points when it 
requires the expenditure of one erg of work to bring a unit of positive 
electricity from one point to the other against the electric force. 

(c') A conductor is said to possess a unit resistance when unit differ- 
ence of potential between its ends causes a current of unit strength to 
flow through it. 

(d'~) Unit of quantity of electricity is that quantity which is conveyed 
by unit current in one second. 

(e'~) Unit of capacity requires one unit quantity to charge it to unit 
potential. 

(/') Unit of induction is such that unit electro -motive force is 
induced by the variation of the current at the rate of one unit of current 
per second. 

(d) " Practical Units and Standards. 1 Several of the above 
' absolute ' units in the C. G. S. system would be inconveniently large 
and others inconveniently small for practical use. The following are 
therefore chosen as practical units : 

" (1) Resistance. The Ohm, = 10 9 absolute units of resistance (and 
theoretically the resistance represented by the velocity of one earth- quad- 
rant per second) but actually represented by the resistance of a uniform 
column of mercury 106.3 centimeters long and 14.4521 grammes in mass 
at C. Such a column of mercury is represented by a 'standard' ohm. 

1 An International Congress of Electricians met at the Columbian Exposition, at 
Chicago, in 1893 for the purpose of adopting practical and standard electrical units. 
These commissioned delegates of many countries agreed upon the following eight 
definitions of terms. 



10 ELECTRO-THERAPEUTICS. 

" (2) Current. The Ampere (formerly called the 'weber'), 
= 10 l absolute units ; practically represented by the current which 
deposits silver at the rate of 0.001118 gramme per second. 

" (3) Electro-motive Force. The Volt, = 10" absolute units, is that 
E.M.F. which applied to 1 ohm will produce in it a current of 1 ampere ; 
being |f |f of the E.M.F. of a Clark standard cell at 15 C. 

lt (4) Quantity. The Coulomb, = 10 1 absolute units of quantity ; 
being the quantity of electricity conveyed by 1 ampere in one second. 

li (5) Capacity. The Farad, =; 10 9 (or one oue-thousand-mill- 
iouth) of absolute unit of capacity ; being the capacity of a condenser such 
as to be changed to a potential of 1 volt by 1 coulomb. The micro-farad 
or millionth part of 1 farad == 10 15 absolute units. 

11 (6) Work. The Joule, == 10 7 absolute units of work (ergs), is 
represented by energy expended in one second by 1 ampere in 1 ohm. 

11 (7) Power. The Watt, = 10 7 absolute units of power (ergs per 
second), is power of a current of 1 ampere flowing under a pressure of 1 
volt. It is equal to one joule per second, and is approximately - T ^ of 
one horse -power. 

11 (8) Induction. The Henry, 10 9 absolute units of induction, is 
the induction in a circuit when the electro-motive force induced in this 
circuit is 1 volt, while the inducing current varies at the rate of one 
ampere per. second. 

1 i Seeing, however, that quantities a million times as great as some 
of these, and a million times as small as some, have to be measured by 
electricians, the prefixes mega- and micro- are sometimes used to signify 
respectively 'one million' and 'one millionth part.' Thus, a megohm is 
a resistance of one million ohms, a micro-farad a capacity of yinriinrtf f a 
farad, etc. The prefix kilo- is used for l one thousand ' and milli- for ; one 
thousandth part ' ; thus, a kilowatt is 1000 watts, and milliampere is the 
thousandth part of 1 ampere. 

' ' The ' practical ' system may be regarded as a system of units 
derived not from the fundamental units of centimeter, gramme, and second, 
but from a system in which, while the unit of time remains the second, 
the units of length and mass are respectively the earth -quadrant and 
10" grammes." ' 

C. DEFINITIONS AND EQUATIONS. 

We are now prepared to follow our analogy in the comparison be- 
tween the flow of water in a tube and the flow of the electric current. 
The first principle to demand attention is that of conductivity. 

Conductivity. Upon the size and construction of a pipe depends the 
amount of energy required to propel water through it. A pipe that has 

1 Elementary Lessons in Electricity and Magnetism. Sylvanus Thompson. 



ELECTRICITY AND MAGNETISM. 11 

a smooth inner surface conducts water more readily and with less loss of 
energy than one whose size is the same but has a rough inner surface. 
Similarly does the flow of electricity depend upon the size and material 
of which the conducting medium is composed. An electric current flows 
through the entire cross-section of a "conductor, so that the resistance 
offered is uniform throughout the material. Different materials conduct 
electricity differently, so that we speak of their relative powers as their 
conductivities. 

Resistance: Ohm's Law. When forcing water through a pipe by 
means of pump pressure, the flowing stream is proportional to the pres- 
sure divided by the resistance. The resistance is the result of friction. 
This applies to an electric current, the current strength being equal to the 
electro-motive force divided by the resistance and inversely as the resist- 
ance of the circuit ; in other words, anything that makes the E. M. F. 
acting in the circuit greater will increase the current, while anything 
that increases the resistance (either the internal resistance in the source of 
E.M.F. itself, or the resistance of the external wires of the circuit) will 
diminish the current. This is Ohm's law, and is frequently expressed thus : 

Volt E. M. F. Electro-motive Force 

Ampere - C = - Current 

Ohm R Resistance. 

True electrical resistance depends upon the nature of the metal of which 
the conductor is composed, the area or diameter of its cross-section, its 
length, and lastly upon its temperature. "The greater the cross-section 
of a conductor the greater is its electrical conducting power, and there- 
fore the less is its resistance ; and the longer the wire the less is its 
conducting power, and therefore the greater is its resistance." 

The relations of the above units may be expressed as follows : 

1 volt x 1 ampere 1 watt 

1 volt -r- 1 ohm = 1 ampere 

1 ampere x 1 ohm 1 volt 

1 ampere x 1 second x 1 ohm 1 joule 

1 ampere x 1 second 1 coulomb 

III. Sources of Electrical Energy. 

The energy required for producing the electric current may be 
derived from 

A. Static ") 

B. Galvanic 

r, r. .V electricity. 

C. Dynamic f 

D. Thermal } 

A. STATIC ELECTRICITY will be discussed in the chapter on the Rontgen- 
ray apparatus. 



12 



ELECTRO-THEEAPEUTICS. 



B. THE GALVANIC CURRENT. 

(a) Primary batteries consist of a series of cells containing a cor- 
rosive fluid, called the electrolyte, in which are two immersed dissimilar 
metals. The employment of the galvanic current, however, is not prac- 
tical in X-ray work, owing to the necessity of employing large numbers 
of cells and the tedious and unpleasant labor occasioned by their use. 
The most reliable of these cells are the Bunsen and the Daniell. The 
latter cell is recognized as a standard, the pressure of one of the cells 
being equivalent to one volt (approximately). These cells may be con- 
nected in one of three ways : 

1. In series. 

2. In parallel. 

3. In groups. 

(1) Series. In order to obtain the highest E. M. F. (voltage) it is 
necessary to connect the cells in l i series : " in other words, the negative 
pole of the first cell is connected with the positive pole of the second 
cell, the negative pole of the second cell with the positive pole of the 
third cell (and so on), and the free negative and free positive poles of the 
first and last cells form the ends or terminals of the "battery." In 
such an arrangement the E. M. F. resulting is equal to the sum of the 
E. M. F. of the individual cells. (Fig. 2.) 




FIG. 2. Connection of the cells in "series." 



(2) Parallel. In order to obtain increased current strength 
(amperage) the cells are connected in a manner known as the "parallel " 
plan (Fig. 3), thus : The positive poles of the individual cells, as well 



" - 12. AMP. 



2 VOUT. 



FIG. 3. Connection of. the cells in "parallel." 

as the negative, are connected in such a manner as to form one pole of 
the battery, positive and the other pole, negative. In other words, 
by the union of the several cells in this manner one large cell has been 
produced. The resulting electro-motive force is the electro-motive force 
of one cell only, while the resistance equals that of one cell divided by 




ELECTRICITY AND MAGNETISM. 



13 



the total number of cells. The amperage is equal to the product of the 
number of cells by the amperage of each individual cell. 

(3) Group. In the "group" method some (Fig. 4) cells are joined 
in series and some are in parallel. Thus, place two cells in one series, 
and the other two in another series ; connect the positive poles of the 
two groups to form a positive pole, and the negative poles of the two 




FIG. 4. Connection of the cells in "groups." 

groups to form a negative pole, the result of this arrangement being to 
halve the number of cells and thus double their size. 

(b) Accumulators, Storage or Secondary Batteries. In 1802 
Gautherot, after laborious experiments, invented the storage battery. 
This was improved upon by 
Bitter in 1803, but the great- 
est improvements were intro- 
duced in 1859 by the elabo- 
rate investigations of Gaston 
Plante. 

Briefly, the principle in- 
volved in the accumulator is 
as follows : We pass an elec- 
tric current into a primary 
cell, containing two plates of 
similar metals. For this pur- 
pose, lead is almost univer- 
sally employed, the chemical 
action from the current result- 
ing in the production of the 
peroxide of lead (PbO 2 ) on 
that sheet of lead to which 
the positive pole is attached, 
whilst the negative plate shows 
the formation of spongy me- 
tallic lead (Pb). The charging current is now removed, the two plates 
of lead are united, and a current having the opposite direction is pro- 
duced. So long as this condition is maintained a new phenomenon is 
observed ; the peroxide of lead suffers a chaDge, being reduced to plumbic 
oxide (PbO), and the spongy lead is changed to the oxide of lead through 




FIG. 5. Diagrammatic view of the inner construc- 
tion of a storage cell. (American Battery Company.) 
1, positive binding post ; 2, negative binding post ; 3 rub- 
ber cap ; 4, hard-rubber vent-tube ; 5, oak case; 6, com- 
pound between rubber jar and oak case ; 7, hard-rubber 
jar ; 8, leaden lug attached to positive plates ; 9, leaden 
lug attached to negative plates ; 10, positive plate : 11, 
negative plate ; 12, sulphuric-acid solution ; 13, soft-rub- 
ber bands ; 14, hard-rubber insulators. 



14 ELECTRO-THERAPEUTICS. 

the process of oxidation, until the two plates are again chemically 
identical ; when this condition is arrived at, the current ceases. A very 
ingenious construction of this principle is shown in Fig. 5. 

A marked improvement over Plante's accumulator is the ingenious 
invention of Faure. In 1881 the latter scientist perfected his invention 
that is now so largely employed. In the Faure system, the active 
material is previously prepared and spread on a suitable support or 
grid mostly of lead in such a manner that it is well retained, which 
offers little electrical resistance. For the positive plates, use is made of 
red lead (Pb 3 O 4 ) and sulphuric acid (50$ ); for the negative plates, either 
litharge (PbO) and sulphuric acid or porous lead. 

Other advantages to be gained in the employment of the accumulator 
are : 

1. Its high E.M.F. (2 volts for each cell). 

2. Its compactness, portability, and durability. 

The capacity of an accumulator is usually expressed in u ampere- 
hours," implying the product of maximum discharging current together 
with the length of time in hours it discharges. The capacity will be 
slightly reduced when an accumulator discharges for a very short length 
of time at a higher rate than the maximum discharge current ; the capac- 
ity depending upon the size, the number of plates and their formation. 
For illustration, if we assume that a certain accumulator has a capacity 
of forty-eight ampere-hours at the maximum discharge of eight hours, 
then we may use the battery normally at one charge as follows : 

With one ampere for 48 hours 

With two amperes for 24 hours 

With four amperes for 12 hours 

With eight amperes for 6 hours 

The utmost precautions must be taken in caring for accumulators ; 
this is of paramount importance, because they are very sensitive to 
shocks and over-exertion, and any bending of the plates is liable to give 
rise to short circuits. There is likewise danger of leakage of acid, break- 
ing of glass cells, etc. Another point to be remembered is that the cells 
must be frequently charged and discharged ; if this is neglected the plates 
will rapidly become impaired. 

It must not be forgotten that the cells must be arranged in a 
"series." 

Sulphuric acid of the best quality must always be used in diluted 
form and free from all impurities. The strong acid should be diluted with 
absolutely pure water to a specific gravity of 1200 or 25 Beaume as shown 
by the hydrometer at a temperature of GO F. In mixing the electrolyte 
the acid must always be poured into the water. The electrolyte should 
never be added to the cells until cold. 



ELECTEICITY AND MAGNETISM. 



15 



In subsequent charges and iii general use, it is only necessary to 
charge until the voltage is 2.5 per cell while charging. It is advisable to 
charge the cells once a week until the voltage per cell is 2.5 volts or 
about one-third the normal charging rate. 

When discharging, the electro-motive force of each cell, as measured 
by tne voltmeter, must not be allowed to sink below 1.85 volts ; thus, in 
the case of a 6-cell battery 11 volts is the lowest limit for the discharge. 

Cells should never be permitted to stand idle if more than 75 per 
cent, of their capacity has been used. 

If a battery is to remain idle for a long time, it should first be fully 
charged and then given a recharge enough to bring it to a boil, and 
left charged. 




T^HEOSTAT 



? \ 




J \ 




i \ 




f \ 



FIG. 6. Diagrammatic view, illustrating the charging of a battery by the ammeter and volt-meter. 

Always see that the cells are well covered with the electrolyte. If the 
latter has been spilt or become partly evaporated, it must be replaced 
with distilled water, and during the charging the top should be open so 
as to allow the escape of the hydrogen bubbles. Avoid unnecessary 
vibration and shaking of the cells. With proper care the accumulator 
should render good service for five to eight years. 

Accumulators may be charged in any of the following five ways : 

1. Primary cell. 

2. 110-volt (direct) current. 

3. Alternating current. 

4. Bicycle dynamo. 

5. Thermopile. 

(1) The method by the primary cell is not practical, because the labor 
involved is unpleasant and tedious, and the process is a most lengthy one. 



16 



ELECTRO-THERAPEUTICS. 



(2) The second method, or the use of the 110-volt (direct) current, is 
the most practical and most easily available method in use. It is neces- 
sary in this method to find the correct polarity of both the 110-volt and 
also of the accumulator. The manner of determining the polarity will 
be discussed in a subsequent chapter. It is necessary by this method to 
offer a resistance to the current, owing to the circumstance that the 
degree of voltage is too great for the accumulator. The means employed 
to effect resistance to this excess of current are either a group of lamps or 
the rheostat. In the latter method the ammeter is placed in the path of 
the current, and the rheostat is so regulated that the exact voltage sent 
to the accumulator can be determined by the amperage recorded by the 
ammeter. (Fig. 6.) 

The simpler and cheaper method is that obtained by the group of 
lamps, mounted on a base and connected in parallel. Each lamp (16 
candle-power) is equivalent to one-half an ampere ; therefore, by this 
method we can accurately estimate the resistance required, by introduc- 
ing that number of lamps which will be necessary to produce the proper 
amperage for charging the accumulator. When the accumulator is not 
properly connected, the lamps burn more brightly than usual. (Fig. 7.) 



O O- 



1 23456 



S.B. 



t / \ f \ 



FIG. 7. Diagrammatic view, illustrating the charging of a battery by a bank of lamps. 

(3) The alternating current presents the disadvantage that, not 
being unidirectional in character, it requires the employment of a 
"converter" in order to produce a unidirectional current, and also to 
provide a low voltage that may be suitable for charging an accumulator. 



ELECTRICITY AND MAGNETISM. 17 

(4) Where it is impossible to obtain a current, as on the battle-field, 
ingenious use has been made of the bicycle, by employing it as a motor 
and attaching it to a dynamo, which generates the current for charging 
the accumulator. This clever thought originated with Major Battersby 
in his memorable Soudan campaign, and the method has been success- 
fully imitated in South Africa. Other means, but not so practical, are 
by water-power, windmill, or by horse- or man-power. 

(5) The fifth and last method is by the use of the thermopile for 
charging purposes, which has found but little favor, and is rarely, if 
ever, employed in this country. 

C. DYNAMIC OB ELECTKIC MAINS are of two kinds : 

(a) Direct. 

(b) Alternating. 

(a) Continuous or Direct. In places where a current from the 
continuous commercial main is available and voltage ranges from 100 to 
250, advantage is often taken of this source of energy, owing to the fact 
that it presents few difficulties and demands but little attention 5 the 
rheostat alone being necessary to regulate both the voltage and amperage. 

(b) Alternating or Street Current. When it is necessary to em- 
ploy an alternating current, there will be required a motor-transformer. 
There are on the market various forms of rectifiers, principal among 
which may be mentioned : i i The Scheidel Western Four Jar Bectifier, ' ' 
"Kny-Scheerer's Valve Cell," and the chemical device of Snook, based 
on the principle that the alternating current is transformed into a unidi- 
rectional current by its passage through a leaden disc immersed in 
ammonium phosphate solution, and thence to the electrolytic interrupter. 
The solutions which are used are usually made very strong, so that the 
percentage concentration is usually above fifty per cent. In the case 
of the neutral ammonium phosphate it is customary to recommend the 
use of a concentrated solution. For work outside of the office my own 
preference is the storage battery, because of its smooth, uniform current. 

I'-, ',.'',; .. 

D. THERMOPILES. 

In 1822 Professor Seel)eck, of Berlin, accidentally discovered that 
when heat is applied to a circuit-junction, a current of electricity is pro- 
duced ; also, that when two junctions are of different temperatures, the 
current produced is directed from the warmer to the colder junction. 
Thermopiles are very seldom employed for working an induction coil. 
Their use is extremely limited in this country. 



CHAPTER II 

THE STATIC, FEANKLINIC, OE FEICTIONAL CUEEENTS. 

THERE are three chief forms of electricity used in medicine and 
surgery : 

Static, Franklinic, or frictional. 

Galvanic, continuous, or direct. 

Faradic, interrupted, or indirect. 

The other so-called varieties, such as the sinusoidal current, high- 
frequency currents, etc. , are modifications of the above forms. 

I. The Static or Influence Machines. 

Ever since static electricity was discovered and the first static 
machine was invented by Otto von Guericke, a burgomaster of Magde- 
burg, Germany, in 1647, the subject has received the closest study from 
scientific minds. Sir Isaac Newton eagerly seized and improved upon 
von Guericke' s discoveries, and these early researches were continued 
through the centuries by English, German, French, and Italian phi- 
losophers, not the least conspicuous among whom may be cited Eamsden, 
Plant4, and De la Fond. While the friction or static machines of these 
searching inquirers are now obsolete, their persistent study laid the 
foundation for the present-day influence machines. 

In the construction of influence machines two important principles 
are carried out : (1) the principle of influence, whereby a conductor 
touched acquires a charge of the opposite kind, and (2) the principle of 
reciprocal accumulation. 

"In Fig. 8 let us, for instance, employ two insulated conductors, A 
and B, electrified ever so little, one positively and the other negatively. 
Let a third insulated conductor C, which we shall call a carrier, be 
arranged to move so that it first approaches A and then B, etc. 

" If touched while under the influence of the small, positive charge 
on A, it will acquire a small negative charge ; suppose that it then moves 
on, and gives this negative charge to B,. and it then be touched while 
under the influence of B, so acquiring a small positive charge. When 
it returns toward A, let it give up this positive charge to A, thereby 
increasing its positive charge. Then A will act more powerfully, and 
on repeating the former operations both B and A will become more 
highly charged. Each accumulates the charges derived by the influ- 
ence from the other. This is the fundamental action of all the modern 

18 



FRICTIONAL CURRENTS. 



19 



influence machines, dating from 1860, the first having been constructed 
by C. F. Varley, consisting of six carriers mounted on a rotating disk of 
glass." 1 

A. TYPES or INFLUENCE MACHINES. 

(a) The Wimshurst influence machine (Fig. 10) consists of two 
circular disks of glass, so mounted as to be rotated in opposite directions, 
at a distance of one-eighth of an inch apart. Each disk is attached to 
the end of a boss of ebonite, upon which is turned a small pulley. Both 
disks are well varnished and cemented. To the outer surface of each are 
twelve or more sectors, made of thin brass and at equal angular distances 
apart. Twice in each revolution, the two sectors situated on the same 




FIG. 8. Diagrarnmatically illustrates the principle of influence and accumulation of static or 

influence machines. 

diameter of each disk are momentarily placed in metallic connection with 
one another by a pair of fine wire brushes, supported at the middle of its 
length, by one of the projecting ends of the fixed spindle upon which the 
disks rotate, the sector plates just grazing the tips of the brushes as they 
rotate. The position of the two pairs of brushes with respect to the fixed 
collecting combs and to one another is variable. 

The fixed conductors consist of two forks, furnished with collecting 
combs directed toward one another and toward the two disks which rotate 
between them, the position of the two forks, which are supported on 
ebonite pillars, being along the horizontal diameter of the disk. To these 
fixed conductors are attached the terminal electrodes, whose distance 
apart can be varied. This form of machine is very efficient and self- 
exciting, provided that a sufficient number of sectors be present, for it is 



66,57. 



1 Sylvanua Thompson, Elementary Lessons in Electricity and Magnetism, pp. 



20 



ELECTKO-THERAPEUTICS. 



found that the machine works at full power after the second or third 
revolution of the handle. The "Wimshurst machine works best when the 
resistance of the discharging circuit is high, and it has been proposed to 
enclose the apparatus in a strong metal case, and to work it under a pres- 
sure of several atmospheres, thus avoiding leakage through brushing. 

The theory of action of these machines is perhaps best explained by 
the aid of the accompanying illustration (Fig. 9), in which, for the sake 
of greater clearness, "two rotating plates are represented as though they 
were two cylinders of glass, rotating in opposite directions, one within the 
other. The smaller inside cylinder, in the figure, represents the front 
plate, and the larger outer, the back plate : the front plate rotates right- 
handedly, and the back plate left-handedly. The neutralizing brushes, 




FIQ. 9. Hlustrates diagrammatlcally the theory of action of a Wimshurst influence machine. 

%, T&2, touch the front metallic sectors, represented near the top of the 
diagram, to receive a slight positive charge. As it is moved onward 
toward the left it will come opposite the place where one of the front 
sectors is moving past the brush %. The result will be that the sector 
touched while under influence by % will acquire a slight negative charge, 
which it will carry onward toward the right. "When this negatively 
charged front sector arrives at a point opposite %, it acts inductively on 
the back sector which is being touched by n 3 ; hence this back sector will 
in turn acquire a positive charge, which it will carry over to the left. In 
this way all the sectors become more and more highly charged ; the front 
sectors carrying over negative charges from left to right, and the back 
sectors carrying over positive charges from right to left. At the lower 



FEICTIOXAL CURRENTS. 



21 



half of the diagram a similar but inverse set of operations take place. 
For when % touches a front sector under the influence of a positive back 
sector, a repelled charge will travel along the diagonal conductor to n 2 , 
helping to charge positively the sector which it touches. The front 
sectors, as they pass from right to left, in the lower half, will carry posi- 
tive charges ; while the back sectors after touching w 4 will carry negative 
charges from left to right. 

"The metal sectors then act both as carriers and inductors. It is 
clear that there will be a continual carrying of positive charges to the 




FIG. 10. Wimshurst influence machine. 

right, and of negative charges to the left. At these points, toward which 
the opposite kinds of charges travel, are placed the collecting combs com- 
municating with the discharging knob." 1 

(&) Holtz of Berlin invented a very powerful influence machine. 
(Fig. 11.) In brief, it consists of two glass plates, the diameter of one 
plate being slightly larger than the other. The plates, though in close 
relationship, do not touch. The fixed plate contains two " windows" 

1 Sylvanus Thompson, Elementary Lessons in Electricity and Magnetism, p. 63. 



22 



ELECTRO-THERAPEUTICS. 



directly opposite one another. Two bits of paper (field plates) are glued 
to the stationary plate, one above the window on the left side, and one 
below the window on the right. From each of these pieces of paper a 
tongue protrudes through each aperture, almost, but not quite touching 
the revolving plate. The plate is rotated in a direction opposite to that 
in which the tongue projects. The prime conductor consists of two 
metallic combs, supported by brass rods with knobs, and mounted on 
glass supports. Two other brass knobs with ebonite handles and knobs 
form the discharging electrodes, through whose agency the spark length 
can be varied. A neutralizing rod to minimize the reversal of polarity 




FIG. 11. Toepler-Holtz influence machine. 

is also provided. Before working the machine, one of the field plates 
must be charged from an outside source and the knobs of the discharging 
rods must be brought together. 

(c) The Voss or Toepler is more self-exciting than the Holtz, but is 
less sure in its action than the Wiinshurst. The Voss resembles the Holtz 
machine in many details, but the moving plates carry a few sectors, and 
these in their rotation touch a pair of brushes carried by two bent arms 
which connect with the field plates, and so convey charges from the mov- 
ing plate to the armature of the fixed field plates. In this country there 
are practically no Wimshurst machines used. They are nearly all 
Toepler-Holtz machines, that is to say, Holtz machines modified so as to 



FRICTIOXAL CURRENTS. 23 

be self-exciting, as invented by Toepler. The Eastern manufacturers are 
largely using the Holtz machines which are excited by a smaller genera- 
tor of the Wimshurst or Toepler type, while mostly all the Western 
manufacturers use the Toepler- Holtz type machine. 

B. CAKE AND MANIPULATION OF STATIC MACHINE. 

In the use of influence machines certain requisites are necessary to 
insure satisfactory results. Chief among these are dry ness and cleanli- 
ness. The accumulation of dust or moisture upon the insulating surfaces 
interferes with the high voltage that must be obtained. The machine 
may be freed from dust and moisture by the use of a dry silk fabric ; 
the oxidation of the metallic sectors can be effectively obviated by cleans- 
ing them with a cloth previously immersed in benzine or gasoline. Alco- 
hol should never be used on any varnished part, as it acts as a solvent 
thereof. During the summer months when the air is often surcharged 
with moisture, it becomes necessary to place in the case a deep tray 
containing fused calcium chloride ; this must be free from impurity, else 
there will result oxidation of the metallic parts. Likewise during the 
torrid season it is found that the current acting on the air in the case of 
the machine, develops a nitrous oxide, and that the nitrogen combining 
with hydrogen forms nitrous acid accumulations, which are detrimental 
to the working of the machine. Wagner uses ventilators in his machine, 
which carry off the nitrous oxides, and recommends that during the sum- 
mer months a dish containing oil, such as boiled linseed oil, be placed 
inside of the case. The oil takes up the active nitrogen because it has 
more affinity for the nitrogen than for the hydrogen. Sulphuric acid is 
also one of the best and most inexpensive driers that can be used in a 
static machine. When it is used, it should be placed in a broad, open 
dish, four or five inches deep, and the full-strength commercial sulphuric 
acid should not more than half fill the dish, as the acid will take up the 
moisture and increase until it has almost doubled its volume ; then it 
loses its efficiency as a drier. 

When used for exciting an X-ray tube, this machine must be operated 
by a power capable of giving a high and steady electro-motive force. In 
cities an electric motor (of the required horse-power) should be em- 
ployed ; in country places water motors or gasoline engines should 
furnish the power ; hand power with this machine is inefficient for 
skiagraphy. 

The length of a spark of a properly working machine ought to 
equal the radius of the revolving plates (approximately). Care should 
be exercised that the neutralizing brushes are so bent as to bring 
them in proper contact with the disks during the whole period of 
revolution. 



24 ELECTKO-THERAPEUTICS. 

The electro-motive force of a static machine depends upon the 
number of revolutions per minute, the size and number of the revolving 
plates, and the general construction and care of the same. 

Glass plates have been in use for more than a century, but mien 
plates possess certain advantages. They are not fragile and less hygro- 
scopic than glass ones, and I have never known them to warp. Because 
of the non-breakable character of mica, a high speed can be obtained for 
the generation of extremely high volume of tension of current. 

Machines not self-exciting have a charge added. This is usually fur- 
nished by a revolving plate to which are fastened several brass sectors. 
On revolving, the latter are brought into contact with the brushes. The 
stationary plate of this machine encloses a sheet of tin-foil or paper as 
a collector. 

A static machine in bad order is said to have "lost its charge" 
when it fails to generate electricity. This may be caused by dampness, 
by the humidity of the atmosphere, or by turning the crank attached to 
the driving-wheel in the wrong direction. 

C. ACCESSORIES. 
THE LEYDEN JAB. 

This is an electro-static condenser, so named from its invention by 
Cuneus, in the town of Ley den, in 1745. In its modern form, a Ley den jar 
is a cylindrical glass bottle, lined inside and out with tin foil, to within 
a short distance of the top. A brass knob inserted in the wooden cover 
is connected with the inner coating by means of a wire or chain. 

Thus we have essentially two conductors, the one almost completely 
enclosed in the other and separated from it only by the thickness of the 
dielectric. If either conductor is put to earth, and the other insulated 
and charged, an opposite and nearly equal charge is induced in the former. 
Ley den jars are frequently connected in series (the cascade arrangement) 
to secure a potential difference equal to the sum of those due to the elec- 
trification of the individual jars, or in multiple, all outside coatings con- 
nected together and inner coatings the same, when increased quantity is 
desired. 

ELECTRODES. (Figs. 12 and 13.) 

These may be of metal or of wood. The metallic electrodes are 
usually of brass, made in a variety of shapes and sizes, and may be 
round, pointed, etc., each being mounted upon a holder of ebonite (vul- 
canite), which acts as an insulator. Boilers are usually made of brass, 
and mounted upon a base or stem of ebonite. The wooden electrodes are 
usually described as discharge electrodes, but they are not so frequently 



FEICTIONAL CUKKEXTS. 



25 



employed as are the metallic variety. Lately glass vacuum electrodes 
have come into vogue. A convenient handle for holding electrodes is 
shown in Fig. 14. 



CHAIN-HOLDER. 

This is usually a brass ring or hook attached to an ebonite stem, and 
is employed for holding the chain which conducts the current from one 



26 ELECTRO-THERAPEUTICS. 

pole of the machine to the electrode (Fig. 15). It prevents bringing the 
chain in contact with the patient, and thus avoids shock. 

MUFFLER. 

This is a cylindrical glass tube, into the ends of which are fastened 
discharge rods. The tube in a horizontal position is held to the discharge 
rods of the static machine by means of wire hooks. The rods of the 
muffler can be readily adjusted by simply turning them in a screw-like 
fashion. This is employed for the purpose of lessening the noise from 
the discharge rods of the static machine. 

PREPARATION OF THE PATIENT. 

When a patient comes for treatment it is necessary to ascertain the 
nature of the disease, before deciding upon the kind of treatment to be 
instituted. If the method selected requires the removal of some of the 
apparel, this should be arranged by the physician' s attendant or nurse 
in a separate room. If much of the clothing is removed, a wrapper or 
loose gown should be thrown over the patient. If the patient is nervous 
it is advisable to instruct the attendant to remove as few of the garments 
as practicable, so as not to offend modesty and in order to lessen the 
fear so frequently induced by the careless therapeutist. Celluloid combs 
and all hair-pins should be removed from the patient's head ; if hair-pins 
be permitted to remain they may cause unpleasant pricking sensations in 
the scalp. 

The patient should be placed in a comfortable position and far 
enough from the machine to prevent shocks from the emitted sparks. In 
damp weather or when the current is not very strong the patient should 
hold the metallic electrode. The cords leading from the discharge rods 
should not touch the ground, the patient, or each other : if they rest 
upon the floor or " ground" there will be a flow of current into the 
earth, if they touch the patient, shock will occur, and if they touch one 
another a short circuit will result. I prefer to treat the patient in the 
sitting posture, as this permits the application of the current to all parts 
of the body, especially if he be seated upon a revolving stool. Occasion- 
ally it may be necessary to adjust his chair so that he cannot rotate it, 
thus allowing a constant flow of current to the part needing treatment. 

POLARITY. 

The polarity of a static current is not of great moment. I have 
heard some patients say that the current of the positive electrode is more 
pleasant than the negative and others affirm the opposite. I am of the 
opinion that there is little, if any, difference between the positive and 



FRICTIONAL CURRENTS. 27 

negative electrodes, so far as the emanating current is concerned. Never- 
theless, this is easily determined by starting the machine with the rods 
slightly apart, and observing that the spark is whitest near the posi- 
tive pole, due to incandescent oxygen being whiter than incandescent 
nitrogen. 

The positive electrode emits a sharp hissing noise when placed in a 
horizontal position. 

No current will flow when a non-conductor is applied to the negative 
discharge, but it will flow from the positive. 

The positive pole can be determined by the collecting combs showing 
points of light, while a brush-like form is evidenced upon the negative 
side. This is best observed in a darkened room while the sliding rods are 
in contact. 

If we separate the balls on the ends of the sliding rods for an interval 
of two centimeters, the spark stream issuing between the rods displays a 
distinct violet portion, which begins at the ball in a bright point. This 
violet portion denotes the negative pole, while the positive pole is 
recognized by a bright area of white light lying near it. 

To reverse the polarity of an influence machine, the usual procedure 
is to ground both terminals, and give the machine a few turns in the 
opposite direction, then remove the grounds and start the machine 
normally. The effect of this operation is rather uncertain, and Herr J. 
R. Januszkiewicz * has devised a system which is more reliable. In this 
one pole of the machine is connected electrically to the inducing plate for 
the opposite pole. The machine is revolved in the normal direction, 
and if the connection then be broken the polarity of the machine will be 
found to be reversed. If the machine is running at a fair speed only a 
momentary connection is needed, but if it is running slowly it may be 
necessary to leave the connection for ten or fifteen seconds. Care should 
be taken that good electrical contact is made. A new pole changer that 
bids to become very popular is shown in Fig. 16, which illustrates the 
wrong connection of the Crookes tube with the static machine, as is indi- 
cated by the heavy lines. By this arrangement we correct the polarity 
without changing the position of the tube, by sliding the rod, H, from 
C to C 1 , the rod carrying the positive pole, which becomes A 1 (anode). 
The negative pole, D, touches the metal D 1 , which is carried, and becomes 
B 1 (cathode). 

IDIOSYNCRASY. 

By this term is meant the susceptibility of the patient to the ac- 
tion of the static electric current. It has frequently been observed that 

1 Physikalische Zeitschrift (Leipsic), abstracted in the Electrical Review, Oct. 
15, 1904. 



28 



ELECTEO-THEEAPEUTICS. 



certain patients are unusually susceptible to static electricity. I have 
seen many cases where a static breeze applied to the head was sufficient 
to cause fainting, or at least dizziness. For such patients it is necessary 
to diminish the strength of the current, also to shorten the length and 
lessen the number of applications. 

THE DOSAGE. 

By this term is meant the length of time required for administering 
the current in the particular case, the intensity of each treatment, i. e., 
the strength of static current produced and applied, and the frequency 




FIG. 16. Pole changer of Betz. 

of its use. The length of each application should be between ten and 
twenty-five minutes. The number of applications will naturally depend 
upon the character of the disease treated, the suffering of the patient, 
and also upon idiosyncrasy. Here is where good judgment and skill on 
the part of the therapeutist are required. It is the general practice to 
give from one to five treatments a week. Frequently the patient inquires 
as to the number of applications requisite before a change in the disease 
will be noted. Unfortunately, we are not able to answer such ques- 
tions satisfactorily. I have seen cases where only three or five treat- 
ments were necessary ; again I have seen cases of the same disease 
where twenty treatments were necessary before a change for the better 
could be observed. 




FIG. 17. Static breeze, concentrated brush discharge, or spray. If the crown is positive, it is a 
contractor of blood-vessels and acts as an antesthetic. If it is negative, it dilates and liquefies and is an 
irritant. The indicator on the machine is turned to the printed word "breeze." 




FIG. 18. Static negative insulation or static bath. Patient holds the negative electrode on an 
insulated platform ; positive is grounded and the sliding electrodes are widely separated. 




FIG. 19. Direct spark. 




FIG. 20. Indirect spark. 



FRICTIONAL CURRENTS. 29 

II. Modes of Application. 

The forms of application used in electro -therapy are : 
CONVECTIVE -\ 
DISRUPTIVE ( DISCHARGES. 
CONDUCTIVE ) 

A CONVECTIVE discharge occurs when electricity of a high poten- 
tial discharges itself at a pointed conductor by accumulating there 
with a density sufficient to electrify the neighboring particles of air 
(these particles then flying off by repulsion), and conveying away 
with them part of the discharge. This form of application is illustrated 
in the use of the static bath, the breeze, and the spray as given off 
from metal electrodes, the high-frequency discharges from glass vacuum 
tubes, etc. 

The DISRUPTIVE discharges embrace the various sparks, the long, 
short, and. friction. 

The CONDUCTIVE discharge is derived from an electrified conductor. 
This may be a continuous current flowing through a thin wire connecting 
the knobs of an influence machine or joining the positive pole of a 
battery to the negative pole. 

A. CONVECTIVE CURRENTS. 

In using the brush discharge (Fig. 17) the patient holds either elec- 
trode while the other, which may be pointed, broom-shaped, or coronal in 
outline, is applied to the area to be treated. This includes the breeze 
and spray (all these terms being synonymous) ; the breeze is the concen- 
trated brush discharge. 

The static bath (Fig. 18), also called static insulation, is administered 
by having the patient on an insulated platform in communication with 
one of the poles of the machine ; after some turns of the handle, it is 
found that he is charged with positive electricity of a high potential, 
while there is a constant waste of electricity from all parts of his body 
and clothing. The effect of the static bath is ultimately sedative and it 
is the form usually employed. It may be greatly intensified by applying 
to the affected part a tinsel rosette instead of a crown piece. Strong 
revulsive effects, leading to actual blistering, may occur when the patient 
is connected directly with the positive pole. Dr. G. Betton Massey, who 
has had a great deal of experience in electro-therapeutics, believes that 
this intensified spray has a deep penetrating action and is of great value 
in intractable chronic rheumatism. 

In the interrupted insulation the negative electrode is held by the 
patient and the positive is grounded. The sliding electrodes are moved 
to and fro, so as to produce an interruption in the current. 



30 ELECTRO-THEEAPEUTICS. 

B. DISRUPTIVE CURRENTS. 

These are subdivided into the direct, indirect, and friction. 

In the direct disruptive current (Fig. 19) the patient is seated on the 
platform, holding either the positive or the negative electrode, the 
remaining electrode being applied to the affected part. The Ley den jar 
may or may not be in the connection. When it is so connected, the cur- 
rent, as a rule, is usually too severe. The spark-gap is wide open. 

Direct sparks are very painful, and are to be used only in cases of 
surface anaesthesia. 

The indirect disruptive current differs from the above in that the pa- 
tient sits on the platform, holding the negative electrode, the positive 
being grounded. If the electrode chain is attached to the water-pipe 
(the indifferent pole being attached to the gas-pipe), more capacity is 
gained, the single sparks give good muscle responses with little pain. 
(Fig. 20.) 

The friction disruptive current differs from the indirect only in that the 
roller electrode is rapidly applied against the affected part. (Fig. 21. ) 

C. CONDUCTIVE CURRENTS. 

Conductive currents are subdivided into the static induced current 
and the wave current. 

The static induced current (Fig. 22) is in connection with both the 
Ley den jars and the patient ; the electrodes must be of metal and applied 
to the bare skin or mucous membrane. The spark-gap is closed at first, 
and then gradually opened to the point of toleration. 

In the wave current the positive electrode is grasped by the patient 
and the negative is applied to the ground ; the necessary electrode is 
block-tin or metallic cloth placed on the bare skin or mucous membrane. 
Begin the application with the discharge rods touching ; then gradually 
separate them until the desired strength of charge is attained. 

The electric souffle or wind is applied by directing the] point of a me- 
tallic uninsulated rod toward, but one foot away from the patient. The 
point is electrified negatively, i. e., if we are using positive electricity. 
The surrounding air particles, becoming electrified, are attracted to the 
nearest part of the patient's body, the stream of molecules producing 
a perceptible current of air. The action of the souffle is sedative. 

Dr. William J. Morton's u Wave Current and High-Frequency Ap- 
paratus m is described as follows : 

"One prime conductor of the static generator is grounded; the 
other is connected with an electrode applied to the patient who is on an 

1 Bulletin Officiel de la Socie'te' Francaise d'Electrothe'rapie, Jan., 1899 ; Electrical 
Engineer, vol. xxvii., March 2, 1899. 




FIG. 21. Friction spark treatment. 










FIG. 22. Static induced current. In this form of static treatment the indicator is turned to the 
word " induced," which connects the Leyden jars. The cords are attached to the binding posts, and 
the sliding electrodes are very gradually separated, as otherwise the shock would be too intense. 



FEICTIONAL CUEEEKTS. 31 

insulating stand. The current received by the patient is due to the 
spark discharge between the knobs of the prime conductors. The patient 
forms one coating of a Leyden jar condenser, the other coating of which 
is the earth and surrounding objects and walls connected electrically 
therewith. 

1 i The greater part of the charge and resulting strain on the dielectric 
(air) will be found at those parts of the patient and the floor or walls of 
the room that are nearest together. 

u If the spark-gap be long, the time of charging by the small con- 
tinuous current will also be comparatively long, because the potential 
must be raised to a high point in order to produce a long spark. The 
duration of the discharge, which will probably be an oscillatory one of 
relatively high frequency because of the small capacity of the condenser, 
will be short. The small continuous charging current will flow through 
the patient without causing appreciable sensation. The sudden oscilla- 
tory discharge may flow over the surface of the patient because of its 
high frequency, and therefore without disagreeable effect. As the length 
of the spark gap is diminished, the time and amount of charge become 
less, with a resulting diminution of sensation." 

The following chart illustrates static modalities in a convenient 
form : 



STATIC 
Compiled and Arranged by 



CLASS. 


NAMK. 


CONNECTIONS FOE POLES 
AND ELECTRODES. 


LEYDEN 
JARS. 


Insula- 
tion of 
Patient 


REQUISITE 
ELECTRODES. 


SPARK- 
GAP. 














Closed to 




Static induced. 


Both to Leyden jars, and 
both to patient. 


Yes 


No 


Metal, to bare 
skin or to mu- 
cous membrane. 


begin and 
gradually 
open to 
tolerance 














of patient. 


Con- 














ductive. 
























Block tin or me- 






The wave cur- 
rent. 


Positive to patient. 
Negative to ground. 


No 


Yes 


tallic cloth to 
bare skin or 
mucous mem- 


As in static 
induced. 












brane. 




Disruptive. 


Sparks : 
Indirect and 
friction. 


Positive to patient or to 
platform. 
Negative to ground. 
Electrode to ground. 


Optional, 
out as a 
rule too 
severe. 


Yes 


Brass 
balls. 


Wide 
open. 


Disrupto- 
convective. 


Brush discharge. 


Positive to ground. 
Negative to patient or to 
platform. 
Electrode to ground. 


No 


Yes 


Made of wood ol 
various sizes 
and shapes. 


Wide 
open. 




Breeze and spray 


Positive to patient or 
platform. 
Negative to ground. 
Electrode to ground. 


No 


Yes 


Usually brass 
point, single or 
multiple.crown 
or broom. 


Wide 
open. 




High-frequency. 


Positive to ground. 
Negative to electrode. 


No 


No 


Special glass 
vacuum. 


Begin %" 
gradually 
regulate to 
capacity 














of patient. 






Both to series interrupter 












High - frequency 
specially inter- 
rupted. 


and 
negative current to elec- 
trode. 


Yes 


No 


As ordinary h. f . 


Wide 
open. 






Positive to ground. 




















Water, block tin, 


Wide 


Con- 
vective. 


Potential 
alternation. 


Positive to patient. 
Negative to ground. 


No 


Yes 


wooden or brass, 
depending upon 


open 
(see re- 












work required. 


marks). 






Usually positive to pa- 














tient or platform. 














Negative to ground. 














NOTE. These are the 












The static bath 
or general 
electrification. 


usual connections. It 
sometimes happens 
that the reverse may 
suit certain cases. 


No 


Yes 


None. 


Wide 
open. 






This does not apply to 














the high- frequency 














currents, where the 














connections cannot 














be changed. 











32 



MODALITIES 

F. HOWARD HUMPHRIS, M.D.. F.R.C.P. 



PHYSIOLOGY AND THERA- 
PEUTICS (after Snow). 


SPECIAL INDICATIONS. 


REMARKS. 


SUBJECTIVE. 
a. Induces muscular contraction 
6. Physiological tetanus. 
c. Local vibratory effect. 
CLINICAL. 
a. Relieves local pain. 
b. Relieves local congestion. 
c. Increases secretion. 


Obstinate constipation. 
Painful neuroses. 


The constitutional effects of this 
current are practically nil. 


SUBJECTIVE. 
a. Local vibratory effect. 
b. Induces muscular contraction 
c. Physiological tetanus. 
CLINICAL. 
a. Diminishes local swelling and 
congestion. 
b. Local pain relieved. 
c. Acute muscular spasm relieved 
d. Increase of local metabolism. 


Insomnia, facial neuralgia, 
gout, sprains, asthma, rheu- 
matism, pelvic congestion, 
lumbago, dysmenorrhcea, im- 
potency, prostatitis, dys- 
pepsia (nervous), gleet, con- 
stipation, goitre. 


During the application of this cur- 
rent to extra-sensitive areas, e.g. 
forehead, eye, ear, nose, and 
throat, it is advisable to do away 
with the negative grounding. 
The two formsof the intensification 
of this current have been omit- 
ted ; they are more local and less 
constitutional in their effect 
when this (the unmodified) can- 
not be used, then the static in- 
duced current is indicated. 


SUBJECTIVE. 
a. Stinging sensation. 
b. Muscular contraction. 
c. Blanching, followed by redness, 
wheals, and even blisters, by 
successive applications. 
d. Increase of local secretion. 
CLINICAL. 
a. Relaxation of muscular spasm. 
b. Relief of pain, 
c. Hyperaemia and swelling less- 
ened. 


Muscular, subacute and 
chronic rheumatism, loco- 
motor ataxia, rheumatoid 
arthritis, all deep-seated 
nervous structural lesions, 
and deep-seated pain, sci- 
atica. Of all local currents 
the spark is the best dia- 
phoretic. 


There is also the direct spark ; it is 
very severe and only of use in 
humid weather. In other re- 
spects it resembles the ordinary 
spark, but the positive connec- 
tion is to the patient and the 
negative to the electrode. 
The currents in order of preference 
for the relief of pain: 
1. Wave. 5. Breeze. 
2. Brush. 6. Spray. 
3. High-fre- 7. Static bath, 
quency. 8. Static induced. 
4. Sparks. 


SUBJECTIVE. 
a. Increases local secretion. 
6. Rubefacient, if pushed, 
c. Local antisepsis. 
CLINICAL. 
a. Relieves local congestion. 
b. Lessens local swelling, 
c. Diminishes local pain. 
d. Promotes local metabolism. 
e. Destroys superficial septic pro- 
cesses. 


Early acute rheumatism, 
sprains, abscess, swelling in 
fractures, early stages in any 
acute inflammation, lum- 
bago, gout, otitis media, 
lupus, tubercle, and any con- 
gestion or stasis, with or 
without germ life. 




The same as the brush discharge, 
but more irritating and less effec- 
tive. 




The positive breeze is stimulating, 
the negative is sedative. . . . 
The negative breeze is where the 
negative pole and the electrode 
are both grounded and the posi- 
tive pole is connected with the 
patient. 




Increase voice range. Piles, 
rectal ulcer, fissure. Ton- 
sillitis, catarrh, hay fever. 
Lupus, acne, and other skin 
affections. 


Ozone evolved . . . Vacuum elec- 
trod es without wire are preferable, 
because they are less liable to 
puncture, cheaper, and equally 
efficient. 




The same as for the ordinary 
high-frequency current. 


Even more ozone is evolved. Note 
that the positive current comes 
from that Leyden jar attached to 
the negative prime conductor, 
and vice versa. 




Painless, simple, and fairly 
effective. The indications 
are the same as for the spark. 


Note that the interruption is effec- 
ted with the stand ball electrode 
and the prime conductor to 
which the patient is connected. 


ALL STATIC MODALITIES : 
Circulatory System. 
a. Lessen arterial tension. 
6. Lessen heart frequency, 
c. Lengthen diastole. 
d. Increase pulse volume. 
Respiratory System. 
a. Rapid and labored breathing 
relieved. 
6. Deepened breathing, with in- 
crease in elimination of CO 2 . 
Nervous System, 
a. Relieve irritability. 
b. Induce soporific effect. 
Vaso-motor System. 
a. Induce diaphoresis. 
b. Induce diuresis, with increased 
elimination of urea. 
Increase general metabolism. 


Where a general sedative is 
indicated. Congestive head- 
ache. As a prelude to, or in 
conjunction with, other 
static modalities. 





33 



CHAPTER III. 
GALVANIC, CONTINUOUS, OE DIEECT CUEEENT. 

GALVANISM is named in honor of Galvani, a physician of Bologna, 
who in 1790 observed that convulsive seizures could be produced in the 
limbs of a dead frog, when certain metals were made to touch the nerve 
and muscle simultaneously. The electrical theory of these motions, how- 
ever, originated with Volta, and, deserving of the credit that his genius 
gave to science, his name is inseparably linked with the subject of 
galvanism. 

BATTERY. 

A galvanic battery is a collection of two or more galvanic cells (Fig. 
23) so connected that the electricity generated by all can be conducted 

Pos/r/vE 
POLE 




FIG. 23. Galvanic cell. 

through a single wire. A cell consists of two dissimilar metals, one of 
which is more readily acted upon by the electrolyte than the other. 
The metals usually selected are zinc and copper. Such a cell is frequently 
referred to as a galvanic couple. 

CONNECTIONS. 

Upon joining the two metals with a wire an electrical circuit is 
formed. If a number of such simple cells are united in "series," the 
zinc plate of one joined to the copper plate of the next, and so on, a 
greater difference of potential will be produced between the copper 
"pole" at one end of the series and the zinc "pole" at the other. 

34 



DIRECT CURRENT. 



35 



Hence, when two or more poles are connected by a wire, there will be a 
greater flow of electricity than would be generated by a single cell. Such 
is the principle of the galvanic battery. The connection of zinc to copper 
throughout the cells makes the latter in " series." By this arrangement 
the amperage is the same as for a single cell, but there is a great increase 
of voltage. 

The cells are said to be in " parallel " when all the zincs are con- 
nected with each other and all the coppers are united to each other. In 
this instance the electro-motive force is not increased, but the strength of 
the current is materially augmented. 

TYPES OF CELLS. 

The cells used in the formation of batteries may be either " dry " or 
" wet." By a "dry" cell is meant the combination of certain metallic 
bodies in such a way as to produce a simple galvanic current without 
making use of an electrolyte; the latter, however, is employed in the 
u wet" cell. Of these the best is the zinc-carbon type, of which there 
are a variety on the market. 

Grove's Cell. This consists of an outer cell of glazed ware con- 
taining an amalgamated zinc plate and dilute sulphuric acid. In the 
inner porous cell, a strip of platinum serves as a negative pole and dips 
into the strongest nitric acid. The hydrogen generated by the sulphuric 
acid acts upon the zinc and transferred to the platinum element meets 
the nitric acid and decomposes it. The platinum is not acted upon by 
the acid. The advantage of the Grove cell is its lowest internal resist- 
ance, and its high electro-motive force. 

Lately the use of dry cells has come into vogue. These are port- 
able, do not need attention as to refilling, etc., and they are in every 
way equal to the best of the wet batter- 
ies. Most of them are made of chloride 
of silver, and are encased in a readily 
portable box. 

The Bunsen cell (Fig. 24) differs from 
the Grove's cell only in that it contains a 
carbon cylinder in place of a platinum plate. 
A common Bunsen cell will give a current 
strength on short circuit of 12 amperes. 

To avoid the annoyance and the dan- 
ger occasioned by the liberation of nitrous 
acid fumes derived from the nitric acid 

employed, chromic acid or a combination of potassium bichromate and 
sulphuric acid may be substituted. This constitutes the bichromate cell. 
This cell is capable of generating a high electro-motive force. 



~c Pi-are 




FIG. 24. Bunsen cell (double fluid). 



36 ELECTRO-THERAPEUTICS. 

The Leclanche cell consists of a porous cup and a carbon plate. The 
positive element consists of a rod of zinc, having a copper wire attached. 
The exciting fluid is a solution of sal ammoniac, in which the zinc dis- 
solves, forming a double chloride of zinc and ammonia ; while ammonia 
gas and hydrogen are liberated at the carbon pole. 

CARE OF THE BATTERY. 

When a battery is frequently and continuously used, it is essential 
that the plates should be kept clean by washing, scraping, etc. The 
solution must be renewed from time to time, and the zincs must also be 
amalgamated. 

When not in use, the metal plates should be withdrawn from the 
solution. If they remain too long a time, a deposit of salt occurs on the 
top of the zincs, which must be removed to insure the correct working 
of the apparatus. The battery is working correctly when bubbles of 
hydrogen are perceived to rise at the sides of the zinc. 

CHARGING THE CELLS. 

Dissolve one and one-half ounces of bichromate of potash in ten 
ounces of cold water, and add one ounce of sulphuric acid. Allow the 
solution to cool. 

POLARITY. 

When a battery has been disconnected and put together again, espe- 
cially if it has many complex parts, there is danger that the positive pole 
may be accidentally connected to the binding screw marked "negative," 
and vice versa. To obviate this error it is necessary to resort to some 
method of testing the polarity of the electrodes. For this purpose the 
use of wet litmus answers admirably. The ends of the wires resting on 
the litmus for a few minutes will show the results of electrolysis, the 
paper becoming reddened by the acid liberated at the positive pole, and 
will turn blue at the cathode or negative pole. Other reagents proposed 
include a solution of phenol-phthalein in dilute alcohol, which gives a 
purple-red color at the cathode. 

A quickly performed test, is to immerse the tips of the wires in a 
saline solution, and it will be found that the negative pole will give off 
double the volume of hydrogen gas in comparison with the oxygen gas 
liberated at the anode. 

WALL CABINET. (Fig. 25.) 

This is of great utility, in that it allows of a wide range and varia- 
tion of current. It is so constructed as to be readily adapted for use with 



DIRECT CURRENT. 



37 



the 110-volt current, with any commercial current, or with a series of 
cells. It combines a galvanic, faradic, and sinusoidal outfit. 

Direct commercial currents are often used instead of cells, but when 
a commercial current is used the means of regulating the voltage is of 




FIG. 25. Wall cabinet for galvanic, faradic, and sinusoidal currents. 

the utmost importance, because when the current passes through the 
tissues at low pressure or voltage, there is more diffusion, and the 
action of the current is more completely confined to the surface of the 
electrodes, and is thus less painful ; whereas, when the current passes 
through the tissues at high pressure (as is the case when a rheostat 



38 ELECTKO-THERAPEUTICS. 

is used for regulating the strength), it does not spread out in passing 
through the tissues, and is thus more painful, but better adapted for 
cataphoresis. 

THE RHEOSTAT. 

The rheostat or current controller is an appliance for the reduction 
of the known electro-motive force. By its use we may also turn "on " 
or "off" the current- supply as gradually as desired. The various forms 
of rheostats have been fully described. 

ELECTRODES. 

These are of various forms and sizes, as the special part and purpose 
may demand. Some of the most useful electrodes are those that are ad- 
justable. The latter are used in central galvanization, galvanization of 
the cervical sympathetic, etc. The adjustable electrode can be readily 
passed under the clothing, thus obviating the necessity of the patient un- 
dressing. Electrodes are made of various substances, sponge or absorl >ent 
cotton being most commonly employed. 

The part to which the electrodes are to be applied must be free of all 
clothing. If the skin is harsh, dry, or hairy, it is well to moisten it 
with a sponge dipped in an aqueous solution of bicarbonate of soda. In 
beginning treatment, the strength of the current used should be regulated 
by the sensations experienced by the patient. A safe rule is to begin 
with a weak current and gradually increase it. It is necessary that the 
sponge attached to the electrode be frequently washed in warm water. 
and those that are much in use should be subjected to the disinfecting 
action of chlorinated solutions. 

GALVANOMETER. 

This is an instrument employed for the purpose of indicating and 
measuring the strength and the direction of a current. The principle 
involved in its construction is that a current of electricity will deflect a 
magnet from its normal position. An ingenious device is the Deprez- 
D' Arson val galvanometer. This electrode bears a milliampereineter and 
allows of application in any position. (Fig. 26. ) 

MlLLIAMPEREMETER. 

This instrument is the standard for measurement of electrical units. 
Under the principles of electricity we observed that the ampere was the 
unit of current strength, but this is entirely too powerful for electro-thera- 
peutic purposes. The resistance of the human body is approximately 
3000 ohms, and the milliampere (the one- thousandth part of an ampere) 
has been found a more convenient unit for that resistance. 



DIRECT CURRENT. 39 

THE GALVANO-FARADIC Box. 

This is a combination of the galvanic and faradic battery. The cur- 
rent from the battery is generated by the Leelanche cell, which contains 
dry sal ammoniac, the necessary water being added when called into 
use. It possesses a great variety of combinations of length of wire, 
enabling the operator to regulate the 
current strength at will. The apparatus 
is provided with a rheostat, a rapid 
interrupter, a pole changer, a slow auto- 
matic interrupter, etc. 

DEFINITIONS OF TERMS. 

Although many of these terms have 
been and will be defined at length, it 
is thought best to tabulate them here, 
so as to present in a compact form the 
commoner expressions employed in 
electro-therapeutics. 

In stabile applications both elec- 
trodes are kept in a fixed position. 

In labile applications one of the elec- 
trodes is moved over the surface, some- 
times both are moved simultaneously. 

A current is sometimes called con- 
tinuous when it is allowed to flow in one 
direction, without interruption. FlG ' *-~^^ t meter - 

A current is said to be interrupted 

when it is broken by the removal of one of the electrodes, or by some 
form of current-breaker in the electrode, or by any method of breaking 
in the circuit. 

Voltaic alternatives is the term applied to those applications in 
which the current is reversed continually, while the electrodes are kept 
firm. 

The ascending current is one where the flow is from the periphery 
toward the nerve centre. 

In the descending current the flow is in the direction from the nerve 
centre toward the periphery of a part. 

By the term dosage we mean the amperage of the current employed 
either in treatment or for diagnostic purposes ; the duration of each ap- 
plication of the electrodes, the amount of pressure exerted, and the size 
of the surface of the electrode applied, are conditions which must be 
taken into consideration when the dosage is to be accurately ascertained. 
(Modified after Rockwell. ) 




40 ELECTRO-THERAPEUTICS. 

METHODS or APPLICATION. 

There are two methods of applying current to a part, (1) stabile 
and (2) labile. 

(1) By the stabile method we mean the keeping of the electrodes 
on spots first ascertained, without moving them about in any direc- 
tion, i. e., the electrodes are retained in stationary positions. After 
ascertaining the polarity, the sponges are carefully moistened, and 
it is then decided which pole is to be applied. After this has been 
done the electrode is gently applied to the part, bearing upon it with a 
slight degree of pressure. The current is now turned on, beginning 
with a minimum degree of current, and gradually increasing it by 
turning the lever of the rheostat ; the amount of current applied de- 
pending upon the susceptibility of the patient. The current should 
not be turned off suddenly, as this is liable to shock and induce fear in 
the mind of the patient. 

The sudden reversal of the polarity in the circuit formed, is also 
liable to produce an unpleasant sensation. Each and every apparatus 
has certain appliances and methods of working them, and the directions 
accompanying the instrument, as outlined by the manufacturer, should be 
carefully followed. 

(2) Labile. This method consists in keeping one of the electrodes 
at a certain indifferent part, while the other electrode is slowly moved or 
strokea over the skin of the part to which the current is to be applied. 
In this stroking, a certain, even, constant pressure should be exerted. 
As in the former instance the current strength should be very gradually 
increased, and at its completion the current intensity should again be re- 
duced as much as possible before removing the electrode. This method 
has a stimulating effect, especially upon the nervo-muscular tissue of 
the part. 

The positive electrode is preferably held stationary at some indif- 
ferent part, as in the right hand when treating the lower extremity. 
The cathode or negative electrode is applied and reapplied alternately. 
When contact is made, a complete electrical circuit results ; when with- 
drawn, this circuit is broken, and no sensation of a current can be felt 
by the patient. 

A method which I prefer consists of an interrupting electrode 
handle. By pressing a small lever and again releasing it, the circuit is 
respectively made and broken. It is easy to manipulate, and the results 
obtained are most satisfactory. 

Another method used is called the ''voltaic alternative," which con- 
sists in alternately reversing the polarity of the circuit by working the 
lever of the commutator or pole discharger. This current is employed 
for diagnostic purposes, as in atrophy of muscles of a part, etc. 



DIRECT CURRENT. 



41 



CENTRAL GALVANIZATION. 



The object of central galvanization is to subject the whole central 
nervous system to the influence of the galvanic current. One pole, prefer- 
ably the cathode, is applied against the epigastrium, whilst the anode 
is placed over the forehead for a period of time, depending upon the 
purpose for which the current is employed. As a rule, an application 
of five minutes duration may be accepted as a maximum. The positive 
pole should then be moved to the vertex, and thence along the course of 
the vagus and over the sympathetic area to the lowest extremity of the 
vertebral column. There may be found on the market a variety of 
portable batteries combining in one a galvanic, faradic, cautery, and 
diagnostic lamp battery. (Fig. 27.) 




FIG. 27. Galvanic, faradic, cautery, and diagnostic lamp battery. 

GALVANO-FARADIZATION. 

By this term we mean the combination of both the galvanic and the 
faradic currents. This may be applied by employing four separate elec- 
trodes, or by connecting the secondary coil and the galvanic battery in 
one circuit, the negative pole of the one with the positive of the other, 
attaching the electrodes to the two extreme poles, and thus passing 
simultaneously both currents through the body. 

CAUTERY BATTERIES. 

These are somewhat different from the batteries above referred to. 
They are subdivided into two classes, the thermo-cautery and the light 



42 ELECTKO-THERAPEUTICS. 

battery. It is here our aim to increase the amperage and not the electro- 
motive force, hence it is necessary that the cells be arranged in the form 
of "parallels." For lighting a small incandescent lamp which requires 
a voltage of 6 c. p., the cells must be connected in a group of two, 
whereby the electro-motive force is halved, and the size of the cells 
doubled. 

Accumulators seem to be more sensitive for this work, especially 
when there is a direct 110 -current available for charging. 

The use of the continuous current in diagnosis and as a therapeutic 
agent, will be found fully discussed in the chapters on Electro -Diagnosis 
and Electro- Therapeutics. 

SINUSOIDAL CURRENT. 

This current is alternating in type, and derives its name from the 
fact that its relation to time follows the law of series. It bears a great 
similarity to the ordinary, pure faradic current, in so far that its motor 
effect also varies according to the rate of alternations. When the alter- 
nations are 20 or less per second, i.e., when they are very slow, the 
effect produced will be a contraction at each end of an alternation. 
When the alternations are more rapid, say, 200 or 2000, the muscular 
contraction becomes tetanic. 

The sinusoidal current has a smooth and gradual variation. It is 
typically adapted for muscular stimulation, and by a properly constructed 
apparatus we may apply a slightly greater milliamperage than the pain- 
producing properties of the primary induction current would permit. 
The ease with which a large number of complete alternations per second 
of this smooth character can be obtained, renders the sinusoidal current 
an excellent nerve sedative. 



CHAPTER IV 
F ARABIC, INTERRUPTED, OR INDUCED CURRENTS. 

Principles of Induction. 

ACCORDING to a natural law it is observed that when two distinct 
circuits are near each other, currents in the one will ^induce" currents 
or, more exactly, electro-motive forces in the other. These induced 
currents are of momentary duration and appear only when the inducing 
current is made to vary, as is instanced when the current is made or 
broken. The current induced at the beginning of the inducing current 
is opposite in direction to the inducing current itself ; and the current 
induced at the break of the inducing current has the same direction as 
the inducing current. The strength of a current so produced is propor- 
tional to the strength of the producing current plus the length of the 
wire subjected to the influence of the inducing current circuit. The 
action of the inducing current in the first coil is augmented if there be 
introduced within this coil a soft iron core, constituting the so-called 
electro - magnet. 

Based upon these principles, first studied by Faraday in 1832, is the 
faradic or induction battery. This battery consists of one or more cells 
placed in circuit with a primary insulated wire surrounding the core, and 
with an automatic device for alternately breaking and making the cell 
current. Over the primary coil is slipped a bobbin having another coil 
of insulated wire wound around it. The secondary coil has no connec- 
tion with the cell, deriving its current by induction, because of its being 
placed over and close to the primary coil and wire. 

MEDICAL INDUCTION COIL. 

The principles of the induction coil are well illustrated in Fig. 28. 
The current makes a circuit from the cell and passes through the 
platinum point, A, to the interrupter, and thence through the primary 
coil : the latter becomes an electro-magnet, which brings about the 
interruptions, through the mechanism of the hammer. 

The heavy line indicates the primary interrupted current. The 
light line indicates the induced or secondary current. 

The intensity of the induced current can be regulated by sliding the 

metallic tube in or out. The arrow I) < >- J indicates that, when 

the sliding tube passes in the direction Z>, there is a decrease of current, 
because of a decrease in the area of the magnetic field, and vice versa. 

43 



44 



ELECTRO-THERAPEUTICS. 



The operation of the coil is as follows : The cell current proceeding 
from the carbon pole of the cell traverses the primary coil, and returns 
to the cell through the interrupter, the platinum points of the latter 
being in contact. In the act of traversing the coil, this current makes 
the core magnetic, which iu turn attracts the small armature on the in- 
terrupter, breaking the cell current ; the magnetism of the core now 
having disappeared, the spring returns to contact, when the process is 
again repeated. On closure of the cell current a reverse induction 
arises in the secondary coil, but this rises slowly on account of self- 
induction between contiguous windings of the primary coil. At the 
instant of opening the cell current, a direct current arises in the sec- 
ondary coil of a much sharper curve of ascent because there is but little 



Int. 




FIG. 28. Medical induction coil. 

self-induction to interfere with it. It is imperative that these coils shall 
not touch each other at a single point. Upon opening or closing the 
primary circuit, there will be established an induced current in the 
secondary coil. This type of electric current is produced by the use of a 
medical Ruhmkorff coil. The screw of the vibrating hammer should 
always be most carefully regulated. Some of the coils have two kinds of 
interrupters accompanying the outfit. One of these is slow, while the 
other is more or less rapid. Occasionally 'the hammer requires a slight 
touch of the finger in order to be started so as to form a circuit 
between the coil and cell or battery. The current produced by a fa- 
radic equipment is alternating in character, as may be readily demon- 
strated when applied to the tissues. Instead of a current from a cell, 
advantage is often taken of a direct 110-current, as is well illustrated in 
Fig. 29. 



INDUCED CURRENTS. 



45 



INTERRUPTER OK RHEOTOME. 



The interrupter which forms an essential part of the battery is the 
vibrating spring hammer of Neef. Many authorities condemn this form 
of rheotome, and recommend one which has double the ordinary spring- 
length, both ends being attached to posts, to one of which is connected a 
tension-screw for regulating the rate of vibrations. The armature is 
attached to the middle of the brass spring and platinum plate for contact 
near the fixed post. Besides regulating the frequency and amplitude of 
the vibrations by the tension- screw, we regulate them also with the set- 
screw carrying the platinum contact point. This device gives easily the 




FIG. 29. Galvanic and faradic lamp controller. 

rate of vibration suitable for muscular contraction, and this is from 1 to 
about 3000 per minute. Vibrations above 3000 per minute are sedative. 
The highest stimulation is from 3000 to 4000 interruptions per minute. 

METHOD OF APPLICATION. 

This method of electrization consists in placing one pole, generally 
the negative, at the feet or coccyx, while the other is applied to any part 
of the surface. The current may be applied (stabile) stationary or 
(labile) moving ; it may be increased or decreased in intensity according 
to the desire of the operator. The person applying it should have some 
experience, so that the very best results may be obtained. 



46 ELECTRO-THERAPEUTICS. 

LOCALIZED FARADIZATION. 

Localized faradization, as termed by Duchenne, or, more correctly, 
polar faradization, in contradistinction to the polar and bipolar method 
of galvanization, is applied in precisely the same manner as is the galvanic 
current. This localized or polar method has eliminated the unscientific 
terms "ascending" and "descending" currents. Nevertheless, we still 
speak of labile and stabile currents, one of the electrodes being moved 
over the surface or both being stationary, and of superficial and deep or 
penetrating currents; the former with a dry metallic electrode to the 
dry skin and superficial nerves, the latter with moist electrodes to the 
deep-seated tissues. 

As A DIAGNOSTIC AGENT. 

As a diagnostic agent, the induction current is of value for de- 
termining the increase or decrease of pathological excitability, and in 
differentiating between central and peripheral lesions. The tension 
current (fine coil) is sedative in character and is valuable in quieting 
hysterical suffering, thus affording differentiation between pain and hys- 
teria in gynecological practice. The irritability of muscle is tested by 
determining the lowest power of the faradic current which will contract 
it, and then comparing with the normal side. In hysterical paralysis, the 
electro-contractility is usually normal, while electro-sensibility is low- 
ered ; in infantile paralysis voluntary contractility is increased, whilst 
faradic contractility disappears. So also in the reaction of degeneration, 
or where a nerve is cut in its continuity, and more or less atrophy or 
degeneration is found in both muscle and nerve. 

As A THERAPEUTIC AGENT. 

As a therapeutic agent the induction current acts on nerves and 
muscles, stimulating each into action or developing anaesthetic effects. 
Its use therefore is demanded in instances of nerve or muscle pain. Bi- 
polar electrodes are most efficient in producing contraction of relaxed 
pelvic muscles, including the uterus itself ; in other cavities and mucous 
membranes its employment is becoming general, through the brilliant 
results achieved by Apostoli. 



CHAPTER V 

CATAPHORESIS. IONIC THERAPY. HYDRO ELECTRIC BATH. 

I. Cataphoresis. 

CATAPHORESIS is the introduction into the human body of remedial 
agents through the physical properties of the electrical current. Were 
the procedure electrolytic, either pole could be applied. 

In 1859 Dr. B. W. Richardson l produced local anaesthesia by apply- 
ing morphia to the anode. Since then various experimenters have 
succeeded in introducing many different medicaments by this process. 
Accurate doses are easily obtained. A piece of tissue paper or absorbent 
cotton is patterned to fit the electrode, and the desired quantity of the 
agent is placed upon it ; the current strength varies from 3 to 20 milli- 
amperes. Cataphoresis is mainly used to impress the skin and mucous 
membranes. Chloroform should be employed only as a counter-irritant, as 
its application produces a dermatitis. Helleborin and aconitin have 
been successfully used. Figs. 30, 30A, 30B, 30C depict various forms of 
electrodes. 

Rockwell believes that "the effects of the galvanic current upon 
nutrition are in part due to the cataphoric transfer of molecules of 
protoplasm and liquid from one cell to another, or from a cell to a capil- 
lary vessel in the path of the anodal stream, and since the diffusion takes 
place more rapidly and more quickly in direct proportion to the current 
strength it behooves us to employ as many milliamperes as feasible in our 
galvanization of the atrophied and paralyzed extremities of poliomyelitis 
and chronic neuritis and peripheral nerve trauma." 

Dr. G. Betton Massey, of Philadelphia, the pioneer in the study and 
application of zinc-mercury Cataphoresis, describes his modus operandi 
as follows : 2 

Technical Details: "A waterproof covered spring cot should be 
selected for the operation, or a thickly cushioned, full-length operation 
table so padded as to keep a large dispersing pad in good contact with 
the back. When the growth is large, as many as six or eight electrodes 
of the Nos. 1, 2, and 3 external type should have wires of appropriate size 
attached to them separately, the distal ends of the wires being securely 
clamped in the one treatment binding post of the meter. They should be 
laid aside separately in a tray in such manner that the wires will not 

1 Medical Times and Gazette, February 12 and June 25, 1859. 
2 From " Conservative Gynecology and Electro-Therapeutics," by Massey, p. 226. 

47 



48 



ELECTRO-THERAPEUTICS. 



tangle when they are brought into use. Several of the electrodes may be 
slightly curved on the flat for greater ease of insertion in a slanting 
manner. 

1 ' The patient having been anaesthetized, the electrodes are amalga- 
mated freely with mercury and one is passed into the periphery of the 
growth with the point directed toward the centre, a slit being made in 
the non-affected skin if necessary. The turning on of the current is then 
begun at once, and when about 150 milliamperes have been attained in 
the circuit another electrode is inserted in the periphery near the first. 
(Fig. 31. ) As the current is gradually increased additional electrodes are 



line of Demarcation 
Zone ofJReaction " 



Areaof5terilizaticm-|- 




Pliant Metallic Plate 

FIG. 31. Massey's method with zinc-mercury cataphoresis, 

inserted until four or five are acting simultaneously with a current 
approaching 200 milliamperes per electrode, or a total strength of from 
600 to 800 milliamperes. The electrodes first placed should now be 
examined closely, and if the necrosed areas about them seem complete 
one is removed at a time, reamalgamated, and placed in a new position. 
By this progressive method the whole of the growth and any diseased 
tissue in the axilla are gradually brought in the area of necrosis, the 
electrodes being replaced if necessary in any intervening spots left unsoft- 
ened. When all hardness has been dispelled, and the coloration shows a 
sufficient extension of the process, the current is turned off, the electrodes 
removed, and the patient put to bed. 

After Treatment: "The part should be dressed with aseptic gauze 
covered with absorbent cotton until the slough comes off, the time taken 
in this process varying from fourteen days to three weeks. In a growth 
that has not been previously in a condition of ulceration no odor will be 
noticed during the process of separation, but in those that were highly 
necrotic it may be wise to apply a powder to the crust composed of pow- 
dered zinc oxide, 32 parts ; carbolic acid, 1 part ; this effectually absorbs 
the odor until the crust separates by the natural process. After the sep- 
aration of the slough the wound is dressed with simple ointment on gauze. 





FIG. 30. Peterson's cataphoric 
electrode. 



FIG. 30A. Sectional view o the same. 



A is a disk, made of metal that will not oxidize. The stem which passes through the hard- 
rubber cover C is held in place by nut D. It also holds the tip for connecting with the battery. B is a 
soft-rubber ring, which is held in place by A, and at the same time it insulates the skin from A, allow- 
ing the current to pass from .1 to the skin of the patient, through the medicated paper contained in the 
cavity formed by A and B. (Courtesy of Waite and Bartlett Manufacturing Co. ) 




FIG. LOB. Three varieties of cataphoric electrodes. 

The one furthest to the left consists of a glass jar, covered with a porous earthy material ; the jar 
is filled with the solution desired. The middle electrode is that of Eisenberg, made of ebonite and 
covered with parchment. The right-hand one is the electrode of Dr. Strauss, which because of its 
small size can be utilized in the treatment of acne, sycosis, etc. (From the catalogue of Reiniger- 
Gebbert and Schall.) 




FIG. 30C. Martin's cataphoric electrode. 

It consists of a metallic plate over which is stretched a piece of parchment, which can be satu- 
rated through the tube with the required medicament. 



IOXIC THEKAPY. 



49 



"~No delay ever occurs in prompt granulation and cicatrization, the 
scar left being of surprisingly small size." 

II. Ionic Therapy. 

The advancements made in physico chemical action during the past 
decade have thrown a new light upon the behavior of salts in the tissues, 
and promise to form the foundation of the explanation of their existence 
in all forms of living matter, as well as much of their therapeutic value. 

The physico-chemical effects of the constant current through the 
living body consists of electrolysis and cataphoresis. Electrolysis is the 
phenomenon which occurs when certain solutions suffer decomposition 
through the agency of the continuous current. The liquids, which when 
thus treated yield up their elements, are designated electrolytes. All soluble 
substances are not electrolytes. Thus, pure water is in itself a non-conduc- 
tor, but becomes a conductor when it holds in solution a salt, acid, or base. 

A. THEORY OF IONS. 

The theory of the ionization of the molecules in solution clears up 
the phenomena of electrolysis. Thus the number of molecules in solution 
is a determining factor for the osmotic pressure, the lowering of the freez- 
ing point, and the vapor tension. "With the establishment of this law, 
certain solutions form an exception, namely, solutions of bases and salts. 
This exception, however, is only apparent, because the molecule is 




Body 



Na Na Na 



c c c c 




+ -t- -- 
K Na Na Na Na 



iici ci ci CL CL i 




FIG. 32. Diagrammatic scheme of the passage of ions (after Zimmern) . A, indicates the metal 
electrode and B, the potassium iodide solution. The drawing on the left illustrates the arrangement 
of the ions before the passage of the current, the right-hand drawing after its passage. 

dissociated in the process of solution, each portion acting as if it were an 
entire molecule. These dissociated portions are designated ions, a term 
first applied by Faraday, who likewise called the positive charge moving 
toward the cathode the cathion, the other the anion, carrying a negative 
charge and proceeding to the anode. 

In illustration, if we dissolve chloride of soda in water, the molecules 
become isolated from each other, a certain number of which suffer still 
further division ; the products of this division being Na ions and CI ions. 
4 



50 ELECTEO-THEEAPEUTICS. 

These ions are not to be confused with atoms, for although sodium and 
chloride ions are present, the solution, of course, possesses none of the 
properties of metallic sodium or free chlorine. If a battery be connected 
with the solution, the Na ions travel to the cathode, whilst the chloride ions 
yield up their charge at the anode (Fig. 32). The sodium ion is designated 
the cathion, the chloride ion is called the anion. Other salts undergo a 
similar dissociation in watery solutions ; K Br forms K and Br ions, 
K 2 SO 4 divides into three ions, two potassium and one SO 4 . According 
to the theory of Arrheuius, these ions, so long as they carry an electric 
charge, do not behave as chemical entities. As soon, however, as they 
lose their electric charge they become subject to the chemical laws of 
affinity and valency. According to this theory, the electro-motive force 
only sorts out the ions which are already separated ; the electric current 
itself is but the transport of the anions to the anode and the cathions to 
the cathode. 

The human body may be regarded as a number of electrolytes 
separated by porous diaphragms. These permeable partitions (the 
membranes separating the elements of various tissues and organs) are 
the seat of the electrolytic exchanges. 

B. PENETRATION OF IONS THROUGH THE INTEGUMENT. 

Leduc proved the penetration of ions by a well-known experiment. 
He took two rabbits and placed them in series in the same galvanic 
current, the electrodes being applied to the flanks. The current was 
conducted to the first rabbit by an electrolytic solution containing two per 
cent, of sulphate of strychnia, it then passed out by a cathode of pure 
water, entered the second rabbit by an anode of pure water and passed 
out by an electrolytic cathode of cyanide of potassium. A current of 60 
to 100 ma. was employed, and after some seconds the reflexes of the first 
rabbit were found to be markedly exaggerated, and shortly thereafter it 
died in a convulsive seizure. The second rabbit became rigid and quietly 
perished. The first death was apparently due to strychnia poisoning: 
the second to hydrocyanic intoxication. (Fig. 33. ) Had the current been 
generated in the opposite direction, the strychnine being made the cathode 
and the cyanide the anode, neither rabbit would have been affected in 
the slightest degree, proving the penetration of the basic strychnia 
cathion and of the acid cyanide anion, and showing that the result was 
not due to ordinary absorption. Again, Leduc has shown that when 
potassium permanganate is used as the cathode, the anion (the perman- 
ganic acid radical) penetrates the skin and colors it ; per contra, no such 
coloration takes place when the permanganate solution is used as an 
anode. The glandular orifices are the avenues by which the ions and 
the electric current penetrate the body. 



IONIC THERAPY. 



51 



SENSATIONS RESULTING FROM INTEGUMENTARY PENETRATION OF IONS. 

The introduction into the skin of each variety of ion is accompanied 
by a special sensation. The anions Cl, Br, and I cause merely a slight 
sensation of heat, the cathions K and Xa provoke painful burning 
sensations. Ba, Ca, Fe, S, Zu, and Mg are all painful. The ions of the 
heavy metals coagulate albumen and are destructive to the integument. 
Au, Pb, and Ag are quite painless. 

It is worthy of note that the inorganic salts dissociate more easily 
than the organic, aud the same is true of bases. 




STRYCH.SULPH.2% WATER | POT. CYANID. 



Cathion. 



Anion 



FIG. 33. Penetration of ions through the integument. (Leduc's Experiment.) 

C. THERAPEUTIC ACTION AS A RESULT OF DISSOCIATION. 

Sodium hydrate has a peculiar action on the tissues, causing corro- 
sion; as the Xa ion is present in many solutions that are non-corrosive 
in character, it is fair to infer that the hydroxyl ion is corrosive in its 
effects. Again, alcohol contains an hydroxyl, and yet it has no such 
corrosive action; this corresponds with the fact that alcohol is not an 
electrolyte, hence there is no liberation of its hydroxyl ion. 

As a general rule one ion is so powerful that, therapeutically, the 
other may be ignored. Thus, in morphine sulphate, the alkaloidal cathion 
is so active that the sulphate ion may be ignored, and the sulphate has, 
therefore, the same effect as the hydrochlorate of morphine 

An interesting study is the consideration of ions in the therapeutic 
employment of the bromides. These have a depressing action on the 
central nervous system, and this is absent in the chlorides of the metals, 



52 ELECTRO-THERAPEUTICS. 

proving evidently that the depressing action is due to the bromide ion. 
Bromated camphor has no such depressant nature. It does not disso- 
ciate with the production of bromide ions, hence it cannot be substituted 
for the bromides. 

D. RESISTANCE OF THE HUMAN BODY. 

This is a most difficult subject and is now, as it has been in the past, 
a problem for scientific inquiry. The determination of the resistance 
of the human body depends on the analysis of the various phenomena 
which have an influence on the total resistance. The order of conduc- 
tivity of the tissues are: Nerve, blood, muscle, skin, tendon, fat, and 
bone. But the lines of electric flux are unequally distributed in the 
space between the electrodes, being denser in the tissues with less resist- 
ance. Efforts have been made to measure the body's resistance by 
Bergonie, Bordier, by the faradic current, the ohm -meter, etc., with 
varying degrees of success. The following is a brief summary of the 
facts relative to the resistance of the body to a continuous current: 

The resistance of the entire body (especially the skin) depends on 
the degree of ionization. The resistance diminishes as the skin becomes 
ionized. The degree of vascularity has little influence on resistance. 

As long as ionization is not complete the resistance of the body is vari- 
able and decreases with the length of time the current has been passing. 

All instruments are useless that do not take into consideration the 
curve of ionization. 

Each variety of ion has its characteristic curve. The curve varies 
with the subject and with the voltage, since ionization occurs more 
rapidly with high voltages. 

E. INVESTIGATORS or THE IONIC THEORY. 

The pioneer in successfully treating disease by electrolytic trans- 
port was Professor Bouchard, although the subject had engaged the 
attention of medical investigators when first mentioned by Palaprat in 
1833; Bruns elaborately discussed the many possibilities of thus trans- 
porting medicaments in 1870; this was followed by papers from the 
most eminent French and German scientists, including: Munch in 1873, 
Louret in 1885, Gartner in 1884, and Wagner in 1886. The subject, 
however, has received its greatest impetus since 1890, through the in- 
vestigations of Edison, Aubert, Labatut, Weiss, Guilloz, Leduc, and 
Frankenhaiiser. 

F. ELECTROLYTIC APPLICATIONS IN THERAPEUTICS. 

With ordinary precautions, the procedure is safe and simple. The 
instrument consists of an ordinary apparatus for the application of the 



THE HYDRO-ELECTRIC BATH. 53 

continuous current. The electrodes are the ordinary electrolytic foot- 
baths, hand-baths, or pads of cotton-wool, etc., impregnated with a solu- 
tion of the electrolyte. For purely local use, the skin under the electrode 
should be compressed so as to produce an anaemia and to reduce the 
circulation at the special site to a minimum, l^ow, it is evident that 
the skin surrounding the electrodes which is not compressed is the better 
conductor; the lines of force are, therefore, denser and the transport of 
ions greater at the periphery. For this reason a piece of gutta-percha 
with a central aperture for the application of the electrode is always 
desirable. Solutions vary from one to three per cent, in strength. The 
degree of concentration of the solution has no effect on ionic penetration. 
The number of coulombs passing through the electrode determines the 
number of ions carried into the body. 

With the medicament as the auion, Klenke and Haasenstein employ 
the iodide of potash or soda in scrofulosis. 

The salicylic ion has been successfully introduced by Bergonie in 
the treatment of articular rheumatism; by Leduc for the alleviation of 
neuralgia. 

G. MEDICAMENTS USED as CATHIONS. 

Aubert of Lyons has employed pilocarpine for local sweating. 
Gartner and Ehrmann have successfully introduced electrolytic ions of 
mercury for the cure of syphilis. 

In the field of anaesthesia Richardson was the first to produce his 
"narcotisme voltaique," by using a solution of morphine, then the 
tincture of aconite, and obtaining with the last-named substance com- 
plete anaesthesia in the ear of a rabbit. The anaesthetic properties of 
cocaine were electrolytically used by Wagner, Morton, and Reynolds. 

Ions of quinine have been successfully employed by Leduc in the 
treatment of certain neuralgias; he also recommends the stimulating 
antiseptic and haemostatic properties of zinc ions in the treatment of 
endometritis, ozaena, and uterine hemorrhages. 

III. The Hydro-Electric Bath. 

The hydro-electric bath is useful in many diseases for its stimulating 
and tonic effects as well as for its trophic influence. It is applicable in 
anaemia, chlorosis, rickets, rheumatism, gout, sciatica, etc. 

The bath itself should be made of porcelain or glazed ware. The 
water should have a temperature of 90-98 F. (32 to 37 C.). Two 
metal electrodes, that must always be kept clean and bright, are placed at 
the head and foot of the bath. These plates are attached to the battery 
by binding screws. The larger electrode is placed at the head of the 



54 



ELECTRO-THERAPEUTICS. 



bath, and is usually 18x12 inches (45x30 cm.); the smaller electrode is 
11x9 (28x23 cm.). In order to localize the current a movable paddle 
connected to the foot- piece is often employed. A wooden rest prevents 
the back and shoulders of the patient touching the head-plate. It is 
immaterial if the feet, with their thickened epidermis, touch the foot-board 




FIG. 34. The four-celled battery of Schnee. 

or not. A part of the current traverses the body, and the remainder 
passes through the water. The resistance in the bath depends upon its 
length, the depth to which it is filled, and the temperature of the water. 
As the current which traverses the water does not affect the patient, it 
follows that only so much water should be used as is required to cover the 
patient comfortably. No salt should be added to the water, as the latter 
thereby becomes a better conductor. 



THE HYDKO-ELECTKIC BATH. 



55 



The duration of the bath should be ten minutes daily for the first 
week, bat after that it should be given on alternate days. The choice of 
current will depend upon the condition present. Thus, in the early stages 
of general neuritis, in acute neuralgia, and in acute sciatica, the direct 
current is indicated. In gout, rheumatism, and arthritic conditions, the 
galvanic current is preferable. The induction-coil bath and the sinusoidal 
currents are useful where general nutritive effects are sought. 
Among local baths may be mentioned : 
THE ARM BATH. 

THE MONOPOLAR AND DIPOLAR BATHS. 
THE ELECTRIC DOUCHE BATH. 

The arm bath is useful in paralysis of the muscles of the forearms 
and hands, in rheumatism and gouty affections, in chilblains, Baynaud's 
disease, etc. The constant current, the current from the coil, or the 



+ + 





FIG. 35. Diagrammatic view of the direction of current, as is illustrated in SchneVs four-celled 

battery. 

sinusoidal current may also be employed. The bath can be arranged in 
any non-conducting vessel ; stone- ware troughs, easily procurable and 
inexpensive, are valuable for the purpose. 

In the monopolar bath only one electrode is immersed, the whole cur- 
rent passing from it to the patient. In the full-length bath, the patient 
grasps a metal conductor, usually a bar or handle which is covered with 
a piece of flannel, and secured above the water level. The current 
passes from the conductor to the hands, thence to the body, and finally to 
the water of the bath to reach the other conductor. 



56 ELECTRO-THERAPEUTICS. 

The electric douche bath originated with Trautwein in 1884. l Dr. 
Guy6not, 2 of Aix les Bains, has described a method of electrical ap- 
plication by the means of douches. The current is led to and from the 
patient by two streams of water, the conductors being connected to 
the nozzles through which the water flows, the jets of water carrying 
the current to the whole surface of the body or to the special part 
desired. Those interested in this method will find a detailed account in 
the original paper. 

Dr. SchneVs four-celled battery is convenient and practicable for 
hydro-electrotherapy (Figs. 34 and 35), in that the patient's extremities 
are alone exposed without additional disrobing. It is comfortable to the 
patient, the current is regulated by a switch-board, and the parts im- 
mersed allow of a large area for cataphoresis. Duration of the bath 
10 to 15 minutes. Current 5 to 30 ma. By means of this bath elimina- 
tion of metallic poisons from the body has often been accomplished. 

1 Zeitschrift f. klin. Med., viii., p. 279, 1884. 

* Revue Internationale d'Electrotherapie, June, 1894. 



CHAPTER VI 
ELECTRO-DIAGNOSIS. 

THE examination of the motor nerves and muscles is of paramount 
importance in electro- diagnosis, consisting in localizing the current with 
the requisite intensity upon these parts. 

The following rules should be followed : Apply one and only one 
pole for each irritation ; the effect of the other pole should be repressed 
as much as possible. 

For the local irritant effect use the active or irritant electrode ; the 
other is termed the indifferent electrode. 

Have the active electrode as small as possible so as to secure the 
greatest density of current. 

Have the indifferent electrode as large as possible, so that the density 
may be slight and ineffective. Place the indifferent electrode upon the 
sternum, the back of the neck, or the small of the back. 

The changes liable to occur in testing nerves and muscles are changes 
in the visible muscular responses. As there may be changes in the 
behavior of the muscles both to the coil and the cells, both forms of exci- 
tation are used in examining a muscle. The active electrode should be 
applied either to the muscle or near its motor point. In testing a muscle, 
the indifferent electrode should be applied to the skin with an even and 
firm pressure. The electrodes and the surface of the body should be well 
moistened. "Water containing a saline diminishes the resistance of the skin, 
but offers the disadvantage of acting upon the electrode. With some 
of the small muscles of the hands and feet, it is convenient to apply both 
electrodes over the part, so that the current may pass directly through. 

The Motor Points. 

These are the points to which the testing electrode should be applied, 
in order to effect contraction in the adjacent muscle, or they are the 
points at which the motor nerve trunks can readily be reached. The 
positions of the motor points vary somewhat in different individuals. 

The motor point can be absolutely located only by experiment. Sub- 
cutaneous fat acts as a barrier, and the examination of the deeper muscles 
is more trying than the superficial ones. The limb should be supported 
by the operator and the muscles relaxed as much as possible. Begin with 
a current capable of producing a small muscular contraction, applying 
the current for a brief period only. 

Points favorable for the stimulation of nerve trunks. 1 

1 The subjoined series of tables are taken from the work of H. Lewis Jones, M.D., 
on "Medical Electricity." 

57 



58 ELECTRO THERAPEUTICS. 

IN THE UPPER LIMB. (Figs. 36, 37, 38, and 39.) 

1. The median, along the inner border of the biceps, and at the bend 
of the elbow. 

2. The ulnar, in the groove between the internal coudyle and the 
olecrauon. 

3. The musculo-spiral, at the point where it emerges from the triceps, 
namely, on the outer side of the upper arm about the junction of the 
middle and lower thirds. 

4. The musculo-cutaneous, between the biceps and coraco-brachialis 
muscles. 

5. The long thoracic (serratus magnus), on the inner wall of the 
axilla. 

6. Tlie supra-clavicular point of Erb. "At a spot one inch above 
the clavicle, and a little externally to the posterior border of the steriio- 
mastoid, immediately in front of the transverse process of the sixth cer- 
vical vertebra, a simultaneous contraction can be produced in the deltoid, 
biceps, coraco-brachialis, brachialis anticus, and supiuator lougus." 
This is a motor point for the fifth and sixth cervical roots before they 
reach the brachial plexus. 

IN THE LOWER LIMB. (Figs. 40, 41, 42, and 43. ) 

7. The anterior crural, in the fold of the groin just outside the 
femoral artery. 

8. The sciatic, just below the gluteal fold at the back of the thigh. 

9. The internal popliteal nerve, in the popliteal space, and to the 
inner side of the tendo Achillis. 

10. The peroneal nerve, just above the head of the fibula, beside 
the biceps tendon. 

IN THE FACE. (Fig. 44.) 

11. The facial, through the cartilage of the lower surface of the 
meatus auditorius. Its chief ramifications can be reached where they 
emerge from the parotid gland. Erb chooses for stimulation three main 
branches of the facial : (a) for muscles above palpebral aperture; (b) 
for muscles in front of upper jaw, between the orbit and the mouth ; 
(c) for muscles of the lower jaw. He tests each of these in two places, 
first at points just in front of the ear, and secondly for (a) at the temple, 
for (b) at anterior extremity of zygomatic bone near its lower border, 
for (c) at the middle of the inferior border of the horizontal ramus of 
the lower jaw. 

12. The fifth, at the supra-orbital foramen, at the infra-orbital 
foramen, at the foramen mentale, on the side of the tongue. 



ELECTRO-DIAGNOSIS. 



59 



Caput externus M. tricipitis 




N. radialis 

M. brachialis interims 

M. supinator longus 

M. radialis externus longus 

M. radialis externus brevis 

FIG. 36. Motor points of the arm. 



M. supinator longus 

M. radialis externus longus 



M. radialis externus brevis 

M. extensor digitorum communis-j 

M. extensor indicis proprius 

M. extensor indicis proprius et M. 

abductor pollicis longus 

M. abductor pollicis longus 



M. extensor pollicis brevis 
M. flexor pollicis longus 



M. interosseus dorsalis I 
M. interosseus dorsalis II 
M. interosseus dorsalis III 




_M. ul nan's externus. 



-M. extensor digiti minimi pro- 
prius. 



M. extensor indicis proprins. 
.M. extensor pollicis longus. 



. -M. abductor digiti minimi. 
.31. iuterosseus dorsalis IV. 



FIG. 37. Motor points of the forearm and hand. 



60 



ELECTRO-THER APE UTICS. 



N. Musculo-cutaneus. M. bicepe. 




N.musculo- Caput in- N. Media- N. ulnaris. Kami N. mediani 

cutaneus. tennis M. nus. M. brachialis pro M. pronatore 

tncipitis. internus. radii terete. 

FIG. 38. Motor points of the arm (front view). 



Eami Nervi mediani pro M. pro 
natore radii terete 

M. palmaris lougus. 



M. ulnariB internus. 



M. flexor digitorum sublimis 
(digitt. II et III.) 



N. ulnaris 

M. flexor digitorum sublimis 
(digitt. indicia et minim) 



Kami volar. prof. Nervi ulnaris. 
M. palmaris brevis. 

M. abductor digiti minimi.. 

M. flexor digiti minimi 

M. opponens digiti minimi.. 



Mm. lumbricales H, III et IV 




..M. radialis internns. 
M. flexor digitorum profundua. 

M. flexor digitorum sublimis 



M. flexor pollicis longus. 
N. medianus. 



M. abductor pollicis brevia. 
M. opponens pollicis. 

M. flexor pollicis brevis. 
M. adductor pollicis. 
M. lumbricalis I. 



FIG. 39. Motor points of the forearm and hand ( front view ). 



ELECTKO-DI AGN OSIS. 



61 



N. cruralis ........ 

N. obturator! us.. 
M. sartorius ....... 



M. tensor vaginae femoris. (Rami 

N. glutsei superioris.) 

M. tensor vaginae femoris. (Rami 

N. cruralis.) 



M. adductor longus -lL//////- -HUM 

Rami N. cruralis pro M. quadrici- WJW:-. v \^S1 M. rectus femoris. 

P!te. vu/lil/i/.-.: VlDl 



pile 

M. cruralis ...................................... 

Eami N. cruralis pro M. vasto in- 



terno.. 



vastus externus. 



* 41 

m 

1 i&jjl M. vastus externus. 

. iMl /, 



Fig. 43.- Motor points of the thigh. 



M. peroneus longus 
M. tibialis anticus 



M. extensor hallucis longus 



Rami N." peronei prof, pro M 
extensore digitorum brevi 



Mm. interosseipedis dorsales. 




N. peroneus. 

M. gastrocnemius externus. 

..M. soleus. 

..M. extensor digitorum longus. 



.M. peroneus brevis. 
M. soleus. 



1 M. flexor hallucis longua. 



..M. extensor digitorum brevis. 



M. abductor digiti minimi 

pedis. 



FIG. 41. Motor points of the leg and foot. 



62 



ELECTRO-THERAPEUTICS. 



Kami inferlores N glutsei inferioris 
pro M. glutaeo maximo 

N. ischiadicus.i 

M. biceps (caput longum) 



M. biceps (caput breve) 



N. tibialis 

N. peroneus 

M. gastrocnemius externus 



M. soleus . 




M. adductor magnus. 

....M. semitendinosns. 
-..M. semimembranosua. 



M. gastrocnemius. 



FIG. 42. Motor points of the thigh and leg (posterior view). 




M. gastrocnemins intcrnus 

M. bolcll.S 



M. flexor digitorum longus 



N. tibialis 



M. abd actor hallucis 



FIG. 43. Motor points of the leg and foot (inner side). 



ELECTRO-DIAGNOSIS. 



63 



1, M. corrugator supercil. ; 2, M. com" 
pressor nasi et pyramidal, nasi ; 3. M- 
orbicular, palpebr. ; 4, M. levator lab- 
sup, alaeque nasi ; 5, M. levator lab. sup- 
Sropr. ; 6, M. zygomatic. minor ; 7, M. 
ilatat. nari um ant. et post. ; 8, M . zygo- 
matic. major; 9, M. orbicularis oris; 
10, Ram. comm. pro Mm. triangular, 
et levator menti ; 11, M. levator menti : 
12, M.quadratus menti; 13, M.triangu- 
laris menti ; 14, Ram. subcutan. colli 
N. facial. ; 15, Ram. cervical, pro Pla- 
tysmat.; 16, M. stern o-hyoideus ; 17, M. 
omo-hyoideus ; 18, M. sterno-thyroi- 
deus ; 19, M. sterno-hyoideus ; 20, M. 
frontalis ; 21, Mm. attrahens et attol- 
lens auriculae ; 22, Mm. retrahens et 
attoll. auriculae ; 23, M. occipitalis ; 10 
24, Nerv. facialis; 25, Ram. auricular, u '""'" :; - 

post. prof. N. facialis; 26, M. stylo-hyoi- 12 -;: 

deus ; 27, M. digastricus; 28, Ram. buc- | * 
cales, N. facialis ; 29, M. splenius capi- 
tis ; 30, Ram. subcutan. maxill. infer.; 
31, Ram.ext. N. accessorii Willisii; 32, 
M. sterno-cleido-mastoideus; 33, M. is 
cucullaris ; 34, M. sterno-cleido-mas- 
toideus; 35, M. levator anguli scap- i 
ulae ; 36, N. thoracic, post. (Mm. rhom- 
boidei) ; 37, N. phrenicus ; 38, M. omo- 
hyoid ; 39, N. thoracic, lateral. (M. 
serrat. magn.) ; 40, N. axillari.s; 41, 
Ram. plex. brachialis (N. musculo- 
cutan., pars N. mediani) ; 42, N. tho- 
racic, ant. (M. pectorales). 




FlQ. 44. Motor points of the head and neck. 



M. rectus ab- 

dqminis. 
(Nervi iutercos- 
tales abdomi- 
nales.) 




M. serratus Mag 
nus. 
M.latissimus dorsi. 



M. obliquus ab- 

dominis exter- 

nus. 

(Nervi intercos- 

tales abdomi- 

nales.) 



M. transversus ab- 
dominis. 



Flo. 45. Motor points of the chest and abdomen. 

IN THE NECK. (Fig. 44.) 

13. The spinal accessory, at the top of the supra-clavicular triangle, 
where the nerve pierces the sterno-mastoid. 

14. The phrenic, on the outer edge of the lower part of the sterno- 
mastoid. 



64 ELECTRO-THERAPEUTICS. 

15. The hypoglossal, along the upper border of the great cornu of 
the hyoid bone. 

16. The recurrent laryngeal, along the outer border of the trachea. 

17. The pneumogastric and glosso-pharyngeal, along the track of the 
carotid artery just below the angle of the jaw. Fig. 45 illustrates the 
motor points of the chest and abdomen. 

When paralysis affects certain groups of muscles, and difficulty is 
experienced, as it frequently is, in tracing the nerve supply of the mus- 
cles involved back to their spinal roots, advantage may be gained by 
employing the table by Dr. Allen Starr. * 

SEGMENTS. 

4th cervical. Diaphragm, levator anguli scapulae, deltoid, rhom- 
boids, spinati, biceps, supiuator longus. 

5th cervical. Rhomboids, spiuati, teres minor, deltoid, pectoralis 
major (clavicular portion), biceps, serratus magnus, supinator longus 
and brevis. 

6th cervical. Latissimus dorsi, pectoralis major, serratus magnus, 
pronators, biceps, triceps, brachialis anticus, extensors of the wrist and 
fingers. 

7th cervical. Teres major, latissimus dorsi, subscapularis, pectoralis 
major and minor, triceps, flexors of the wrist and fingers. 

8th cervical. Flexors of the wrist and fingers, extensors of the 
thumb, intrinsic muscles of hand. 

1st dorsal. Extensors of the thumb, intrinsic muscles of the hand 
(thenar, hypothenar, interossei). 

For the lumbar enlargement Dr. de Watteville 1 gives the following 
distribution : 

3d lumbar. Ilio-psoas, sartorius, adductors, extensor cruris. 

4th lumbar. Extensor femoris et cruris ; peroneus longus ; adductors. 

5th lumbar. Flexors and extensors of toes, tibial, sural, and peroneal 
muscles, extensors and rotators of thigh, hamstrings. 

1st sacral. Calf, hamstrings, long flexor of great toe, intrinsic 
muscles of foot. 

2d sacral. Intrinsic muscles of the foot. 

Dr. Herringham* has also tabulated the results of numerous dissec- 
tions of the brachial plexus in new-born infants as follows : 

1 Brain, 1894, 

2 Lancet, July 14, 1883. 

3 Proc. Roy. Soc., March, 18G<5. 



ELECTBO-DIAGNOSIS. 65 

USUAL, NEKVE SUPPLY. 

3d, 4th, and 5th cervical. Levator anguli scapulae. 

5th. Bhomboids. 

5th, or 5th and 6th cervical. Supraspinatus, infraspinatus, teres 
minor. 

5th and 6th cervical. Subscapularis, deltoid, biceps, brachialis 
anticus. 

6th cervical. Teres major, prouator radii teres, flexor carpi radialis. 
Supinator longus and brevis. Superficial theuar muscles. 

5th, 6th, and 7th cervical. Serratus magnus. 

6th or 7th cervical. Extensores carpi radiales. 

7th cervical. Coraco-brachialis, latissimus dorsi, extensors at the 
back of the forearm, outer head of triceps. 

7th and 8th cervical. Inner head of triceps. 

7th, 8th, and 1st dorsal. Flexor sublimis and profundus, flexor carpi 
ulnaris, flexor longus pollicis, and pronator quadratus. 

8th cervical. Long head of triceps, hypotheuar muscles, interossei, 
deep thenar muscles. 

The pectoralis major from 6th, 7th, 8th, and 1st dorsal. 

The pectoralis minor from 7th, 8th, and 1st dorsal. 

Hints for Practical Testing. 

Always begin testing with the faradic current and finish with the 
galvanic current. Use very weak currents. If the muscles do not 
respond to these currents, increase the strength of the latter. The 
operator should first apply the current to his own person, so as to reas- 
sure the patient. With battery currents start with about 16 cells for 
the limbs and 8 cells for the face. The testing electrode should be the 
cathode. If upon passing no noticeable contraction is discerned in the 
muscles, increase the number of cells, upon the first closure contraction, 
look for the most effective spot for stimulating the muscle, and compare 
the AC1C with the CC1C. Observe the character of the contraction, 
whether quick or sluggish. Compare the direct with the indirect stimu- 
lation through the nerve trunk ; compare the reactions obtained with 
those of the unaffected side. 

Disease or injury may cause quantitative changes or changes in the 
amount of reaction to a stimulus, the quality of the reaction remaining 
unaltered, as is exemplified in simple increase of excitability and simple 
decrease of excitability to coils and cells. 

In unilateral disease, the recognition of increased or decreased ex- 
citability is easy when this increase or decrease is marked; but when 
slight, there are many disturbing factors that may lead to an error of 
judgment. 



66 ELECTRO-THERAPEUTICS. 

With the battery current, the galvanometer is a reliable guide. 
Unequal pressure of the electrode, when comparing two points, may 
cause an apparent difference in irritability. The resistance of the skin 
is likewise inconstant during a test. 

Increased irritability usually occurs in those conditions presenting 
increased reflexes, as in chronic myelitis, in degeneration of the lateral 
columns, in heuiiplegia, and in tetany. 

Decreased irritability is evidenced in many diseases, offering quali- 
tative changes also when the condition is more severe. Thus in neuritis 
we may observe either qualitative or quantitative changes, according as 
the attack is mild or severe. 

Qualitative changes are changes affecting the quality of the reaction. 
This includes the reaction of degeneration, both complete and partial, 
also the myotonic reaction, etc. 

Reaction of Degeneration. (De. R.) or (R. D. ) 

This term was proposed by Erb, to signify the series of changes 
occurring in electrical irritability, both qualitative and quantitative, 
owing to a certain definite morbid condition of nerves and muscles. 
The effect of the faradic current diminishes and disappears, but with the 
galvanic current, decided changes are manifested. Lesions of motor 
nerves, either at the spinal centre or in the course of peripheral dis- 
tribution, of sufficient importance to produce paralysis, will rapidly 
show pronounced galvanic and faradic changes. The nerve will exhibit 
a progressive diminution of electrical excitability, and a few days sub- 
sequently it will have ceased entirely. Rarely a fortnight elapses before 
complete cessation of excitability is noted. The point of departure is 
always at the extremity, nearest the injury or lesion, degeneration pro- 
ceeding thence toward the periphery. When reparative action has 
begun, excitability returns, recovery showing itself at the point of begin- 
ning degeneration. Frequently muscles may respond to the patient's 
will, but they do not respond to electrical currents ; showing that while 
the nerve will transmit the voluntary impression, it will not necessarily 
transmit other impressions. 

DEGENERATION OF MUSCLES. 

In degeneration, muscles differ from nerves in their electrical reac- 
tions. With the faradic current, however, the reactions are identical both 
in quality and quantity. The faradic current has no effect on muscle 
tissue, save for the nerve supplying it. With the galvanic current, mus- 
cular tissue for the first few days contracts, with a somewhat lessened ac- 
tivity ; its response to a certain strength of current is not so marked as in 



ELECTEO-DIAGNOSIS. 67 

the normal condition. For several succeeding days, the irritability of 
the muscle is increased. This may last for weeks, and sometimes during 
this condition a change in the normal sequence of contraction occurs, 
the contractions changing in character as well as in quality. They assume 
a slow tetanoid form, which continues during the flow of the current, 
the strength of the current required being notably small. Soon in the 
stage of degeneration the AnCIC = CaCIC, and a little later exceeds it ; 
this is accompanied by the CaOC gaining upon the AnOC, but never 
being equal to it. Thus we obtain the following formula for the normal 
muscular reaction to galvanism : 

CaCIC > AnCIC > AnOC > CaOC. 

For the reaction of degeneration, the formula : 

AnCIC = CaCIC or AnCIC > CaCIC > AnOC diminished, but always > CaOC. 

PARTIAL, BEACTION OF DEGENERATION. 

This term is applied to cases in which contraction is evidenced to 
some degree by the coil ; but to the battery current the response is 
sluggish. 

The existence of partial reaction of degeneration makes it necessary, 
when testing, always to corroborate the results obtained from the faradic 
by employing the galvanic current. In partial reaction of degeneration 
there is found an alteration in the coil reactions, but this may be over- 
looked, and thus conclusions arrived at from the presence of coil reac- 
tions would be wrongly interpreted. The degree of sluggishness of con- 
tractions may vary within wide limits, the reaction to the coil may be 
faint or very strong. By some it is held that partial reaction of degen- 
eration represents a changing state of the nerve or muscle, and that a 
change to complete reaction of degeneration on the one hand, or to a 
normal reaction on the other, may be looked for in cases showing partial 
reaction of degeneration. 

TO RECAPITULATE : 

Electrical Reactions as a Diagnostic Aid. 

In electro -diagnosis the following statement is invariable : 
A healthy nerve and muscle, with the same strength of current, respond 
more readily to the negative pole than to the positive. 

IN HEALTH. 

Normally, electrical examination of nerve and muscle is found as 
follows : 



68 ELECTRO-THERAPEUTICS. 

Upon closure of the faradic current there will occur a ready sharp 
contraction to either electrode, this contraction continuing while the 
current is passing. On the other hand, the phenomenon of contraction 
with the galvanic current depends upon the pole applied to the nerve, and 
also whether the circuit is opened or closed. Thus, if we apply the 
negative pole to the nerve, and a weak current is passed, no contraction 
will be observed during the time that the current is passing. With a 
current just sufficiently strong, there will be noted a quick, sharp con- 
traction the instant that the circuit is closed, but not at its opening ; per 
contra, with the positive pole and the same current strength, there will 
be absence of contraction, either upon opening or closing. However, 
if the strength of current is gradually augmented the next contraction 
will be observed, when, with the positive pole on the nerve, the circuit is 
opened, then follows one with the positive closing, and lastly with the 
strongest, perhaps painful, current a contraction will be noted with the 
negative opening. 

IN DISEASE. 

In disease wide variations in these reactions may readily be recog- 
nized : The faradic current elicits a lessened or sluggish response, or its 
entire absence may be noted. With the galvanic current the contraction 
is slow and sluggish ; the anodal closure contraction becoming equal to or 
even greater than the cathodal closure contraction. On the other hand, 
it may be impossible to obtain a contraction with either the faradic or the 
galvanic current, no matter how strong the current may be. 

This naturally leads to a consideration of the l ' reaction of degenera- 
tion" (De R.), which depends upon the changes occurring in a motor 
nerve and muscle which have been disconnected from their trophic 
centre either as a result of disease of the centre or of the nerve itself. 

Degeneration is noted in the following order: First, the terminal 
nerve-fibres, then the end-plates, and finally the muscle itself degenerates. 
Thus, within three or four days after a spinal nerve has been deprived 
of the trophic influence of v the motor cells of the anterior horn, there 
ensues a decreased reaction to either the galvanic or faradic current; 
indeed, the faradic response may soon disappear altogether. In ten 
days or two weeks, however, the response to galvanism may increase 
beyond the normal. If the lesion is temporary and removable, the 
affected muscles begin to regain their power, and within a short interval 
the responses show a marked improvement and gradually return to the 
normal. The response to faradism (made up of excessively short, rapid 
currents) is first to disappear, due to the fact that as the nerve-fibres 
degenerate it requires a current of relatively long duration to stimulate 
them. In brief, it may be stated that in the reaction of degeneration the 



ELECTRO-DIAGNOSIS 69 

employment of the faradic current affords no response; to the galvanic 
current there is noted a sluggish contraction and as good or better anodal 
than cathodal response. 

As the peripheral nerves do not degenerate unless there are lesions 
of the lower motor neurone, the response of the muscles to faradism and 
the occurrence of normal reactions to the galvanic current allow the 
exclusion of diseases of the anterior horns and roots and the peripheral 
nerves, but not diseases of the central nervous system. If the reaction 
of degeneration occur, we may eliminate cerebral disease, functional 
paralysis, and because of the fact that De R. occurs very late in the 
disease, we can negative primary affections of the muscles (dystrophies); 
resting the diagnosis either on disease of the anterior horns and roots or 
of the peripheral nerves. 

THE SENSORY SYSTEM. 

Little can be said on the subject of alterations in the electrical 
reactions of the sensory nerves, and but faint light can be thrown on the 
irritability, conductivity, location, etc., of the sensory nervous system. 
An increase in the impressions conveyed by the cutaneous filaments of 
the sensory nerve-fibres indicates electrical cutaneous hyperaesthesia, 
while impairment of this function, corresponding largely with the definite 
reactions of the motor system, constitutes electrical cutaneous anaesthesia. 
In diseases involving the sensory tracts of the cord, the diagnosis is 
materially aided by finding this anaesthesia and hyperaesthesia. 

NERVES OF SPECIAL SENSE. 

Under this heading we shall only notice the auditory nerve, which 
allows of material aids in diagnosis, through its irritablity in tinnitus 
aurium. Like motor nerves, the auditory responds more readily to 
cathodal than to anodal stimulation, the response being the production 
of a subjective sensation of sound ; in certain abnormal conditions the 
auditory nerve answers to electrical currents more readily than it does 
in health. In these cases it is contended that a state of hyperaesthesia 
exists in the nerve, and that tinnitus is an expression of that state. To 
test the auditory nerve, use a bifurcated electrode applied to both ears at 
once. By this method there is less likelihood of provoking giddiness. 
If a binaural stethoscope is used as a temporary expedient, the lower 
portion should be removed, and the tubes closed up with small corks ; 
the battery wire is attached to the metal and the other electrode is 
placed indifferently. 



CHAPTER VII 

ELECTRO-PHYSIOLOGY. 

THE diagnosis of pathological conditions can in many instances be 
more accurately investigated by a thorough preliminary understanding of 
a study of the electrical current influences upon the normal physiological 
functions. 

INFLUENCE OF ELECTRICITY UPON MOTOE NERVES AND MUSCLES. 

The motor nerves, when irritated by the galvanic or faradic current, 
give rise to a muscle contraction. According to Du Bois-Beyniond : 

"The absolute amount of the density of the current at any certain 
moment does not act as a stimulant to the motor nerves, but merely the 
change in its amount from one moment to another, i. e. , in the density ; 
these act so much more powerfully the greater they are in a unit of 
time, or, their amount being equal, the more rapidly they occur ; most 
powerfully therefore upon sudden closure and opening of the current. 

" Thus the reason of the marked irritative effect of the faradic cur- 
rent on motor nerves at once becomes apparent ; whilst, on the contrary, 
a constantly flowing galvanic current, or a very gradual increase or 
decrease in the current strength, produces no stimulation whatsoever. If 
induction currents are applied to a motor nerve, a series of brief muscular 
contractions, corresponding to the strength of the induced current, will be 
produced ; these contractions necessarily being greater during the open- 
ing than during the closing current of the secondary coil. A long series 
of these irritations results in a tetanic contraction." 

PFLUGER'S LAWS OF CONTRACTION. 

" With weak currents in both directions, contraction occurs on closure 
alone, but none is produced on opening ; the contraction on closure of 
the ascending current is somewhat stronger than that of the descending. 

"With moderate currents contraction occurs on opening and closing 
in both directions ; but the former are always weaker than the latter. 

"With very strong currents (never employed upon human beings) 
contraction occurs on opening, but none on closure of the ascending cur- 
rent ; and it also occurs on closure, but not on opening of the descending 
current." 

These laws only hold good when the nerve is laid bare and well 
isolated. 
70 



ELECTEO-PHYSIOLOGY. 71 

In illustration of the above laws we need only refer to the irritative 
effect produced by the galvanic current, which occurs only at the poles, 
and starts from them, and note that the irritation upon closing the circuit 
occurs only at the cathode, and upon opening, only at the anode. Long 
ago it was proved that the irritant action of the cathode was greater than 
that of the anode ; thus the irritation on closure is greater than at the 
opening, with the same intensity of current. Likewise the central part 
of a nerve is more irritable than the peripheral portion, and with very 
strong currents considerable resistance occurs at both poles and increases 
with the strength and period of closure of the current. Furthermore 
motor nerves are non-irritable to the transverse passage of the faradic 
or galvanic current, and a motor nerve which is still connected to a 
central organ has its opening contraction of the ascending current con- 
siderably later than when the (motor) nerve is isolated. 

Thus far we have been dealing with electrical currents on motor 
nerves studied physiologically, but the results obtained are not analogous 
with the practical results obtained by the physician. The latter deals with 
nerves, surrounded by tissues of good conduction and which are followed 
by large numbers of threads of currents ; illustrating the absolute futility 
of maintaining a uniform density of current in a nerve. The greatest 
density of current must occur directly at the electrodes. Because of the 
various threads of current, the direction of the latter must be omitted 
from consideration in applying electricity to the healthy human body. 

In the polar method of examination, one electrode, called the 
11 active," is applied closely to the nerve and then connected with either 
the anode (An) or cathode (Ca) of the battery. The other electrode, 
termed the "indifferent," is placed upon some distant part of the body, 
as the sternum, spine, epigastrium, etc. If the cathode is upon the 
nerve and the circuit is closed, the term u making a cathode closure" 
is employed, and is written CaCl ; if the circuit is open it is desig- 
nated " cathode opening," and is written CaO, and similarly with the 
anode. 

Begin with a definite strength of current by examining CaCl in 
about three closures, at the same time studying the CaO, and thus also 
with the anodal contractions. 

For the opening contraction, keep the current closed for a brief 
period, as the irritability on opening the circuit is thus augmented. By 
an increase of current, we gauge the degree of intensity of current for 
the various forms of contraction. 

By this method it is readily demonstrated that with most of the 
motor nerves the cathode chiefly produces stimulation on closure, the 
anode principally on opening, and that the stimulant action of the cath- 
ode is much greater than that of the anode. 



72 ELECTRO-THERAPEUTICS. 

In medicine three stages of contraction are distinguished : 

First stage (feeble current) CaClC. 

Second stage (moderate current) CaClC' is stronger. AnCIC and 
AnOC also occur and are for all practical purposes of about equal 
strength. 

Third stage (strong current) CaClC" becomes tonic and equals 
CaClTe ; AnCIC (and especially AnOC') becomes more powerful and at 
the same time weak CaOC occurs. 

UPON VOLUNTARY MUSCLES. 

Du Bois-Reymond's law of motor nerve stimulation holds equally 
good for muscle stimulation. 

1 i Currents of very high duration occasion less reaction upon muscu- 
lar tissue than upon nerves ; but the summation of the individual con- 
tractions produced by each single induction stroke results in tetanus, as 
was observed in the excitation of nerves. The laws of muscular contrac- 
tion produced by galvanism are analogous to those already formulated. 

' ' Depending upon the strength of the current, living muscles react 
with more or less tetanic contraction to faradism, and with single con- 
tractions to individual contraction currents. This occurs so much more 
readily the nearer the electrodes are approximated to the points of 
entrance of the motor nerve-branches into the muscle, or touch these 
points (motor points) directly. 

" The galvanic reaction of the muscles occurs in such a manner that 
they respond to stimulation with both poles, by a closure contraction 
alone, the opening contraction being absent, or obtained very excep- 
tionally. To some extent, an isolated irritation of the muscles of the 
body by the galvanic current may effect a local galvanization, founded 
upon the same principles and methods as local faradization. Another 
very important group of effects are the modifying, irritability changing, 
electrotonic action, which are manifest in the electrical, thermal, or me- 
chanical irritability of motor nerves (and muscles) during the passage 
and after the cessation of the current." 

ELECTROTONUS. 

When a galvanic current is passed longitudinally along the course 
of a motor nerve, the nerve changes its irritability along its entire 
length, which is especially pronounced in the vicinity of both poles. At 
the cathode and its vicinity there is an .increase in the electrical, me- 
chanical, and thermal irritability, and that portion of the nerve is said 
to be in a state of ' ' catelectrotonus ; " at the anode and its vicinity it is 
decreased, whence the term ' ' anelectrotonus. ' ' Both increase with the 
duration and intensity of the polarizing current, and touch one another 



ELECTRO-PHYSIOLOGY. 73 

in an indifferent point of the intrapolar region. Upon breaking the 
current, the negative modification of the irritability of the anode 
(anelectrotonus) is immediately changed to a marked positive, requiring 
some time for its disappearance ; at the cathode, a brief negative irri- 
tability rapidly followed by a vigorous positive modification, with an 
increase of irritability which gradually returns to the normal. Thus 
after breaking the current, there remains a normal or less prolonged 
increase of irritability at both poles. 

SENSORY CUTANEOUS NEKVES. 

The application of the galvanic current to the skin produces a 
pricking followed by a burning sensation, which may increase, and cause 
intense pain. Possibly these sensations may in a large measure be due 
to the effects produced by the chemical substances liberated at the surface 
of the body by electrolysis ; many asserting that the reaction of the sen- 
sory terminal organs is not identical with the reaction observed in the 
conducting paths. 

The sensory irritations appear not only in that part of the skin 
covered by the active electrode, but likewise in the area of distribution 
of that nerve or nerves lying in the territory of the electrode. 

SENSORY NERVES OF MUSCLES. 

These can only be studied satisfactorily when muscles have been ex- 
posed by wounds, or in complete anaesthesia of the skin. Every vigorous 
muscular contraction is accompanied by a distinct sensation, which has 
nothing in common with cutaneous sensibility, and which may increase 
to actual pain during tetanic contraction (electro- muscular sensibility). 
The sensation produced is in direct proportion to the degree of muscular 
contraction, and is usually described as dull and tensile ; it is likewise 
produced with strong galvanic currents as soon as they produce tetanic 
muscular contractions. 

UPON THE SPECIAL SENSES. 

To the galvanic current, the special senses respond with readiness by 
means of their specific sensations, the latter being dependent upon the 
influence of both poles. The optic nerve or retina reacts quickly to the 
galvanic current. Pass a current through the temples or cheeks and 
upon making or breaking the current a flash of light will appear. Ap- 
ply a stronger current some distance from the eye (as upon the neck or 
chest or back), and the same phenomenon resulting illustrates the great 
sensitiveness of the retina to galvanic currents. The muscular tissue of 
the iris promptly responds to the faradic current ; even the pupillary 



74 ELECTKO-THERAPEUTICS. 

sphincter can be made to contract independently, which may also be 
accomplished by stimulation of the motor oculi and the cervical 
sympathetic nerves. 

The auditory nerve being very deep seated, its excitation can only 
be effected by a current that must be so strong as to produce most 
unpleasant associated phenomena. Galvanization of this nerve is accom- 
plished by placing a large moist sponge electrode immediately in front 
of the auditory canal, pressing slightly upon, but not occluding the 
tragus. The indifferent electrode is placed upon the back of the neck. 
The strength of the current being increased, repeated cathodal closures, 
at times And, are made, or if the irritability is very slight, repeated 
changes of polarity are to be instituted. The normal auditory apparatus 
therefore, only gives a sensation at closure upon irritation with the Ca, 
and only on opening upon irritation with the An. Healthy individuals 
usually hear sounds described as whistling, buzzing, hissing, or roaring. 
The AnO reaction is, as a rule, feeble and short. By an increase in 
the strength of the current, the auditory sensations increase in intensity, 
distinctness, and duration, and assume a more musical and whistling 
character. 

By the galvanic taste is meant the peculiar acid, salty taste which is 
produced by placing the simplest galvanic element (a piece of zinc and 
copper) on the tongue, or by passing stronger currents through the 
cheeks, throat, temples, etc. 

If two medium electrodes be placed upon the cheek, gustatory sen- 
sations appear at both poles. The sensation is more marked at the anode, 
where it is metallic, alkaline or perhaps very acid. At the cathode it 
is milder, biting and salty. The sensation is present at making, breaking, 
and during the passage of the current. 

On the olfactory nerve, galvanic stimulation is little understood. 
By some it is said to produce a phosphorus-like odor. 

UPON THE SYMPATHETIC SYSTEM. 

The study of the galvanic current upon the sympathetic 
system needs to be further prosecuted. Physiologists are too problem- 
atic in their deductions as to the functions of the sympathetic nerves 
and their interposed ganglia, to lead to other than hypothetical con- 
clusions. 

Faradization of the cervical sympathetic causes contraction fol- 
lowed by dilatation of the vessels of the corresponding side of the 
head and face ; slight exophthalmos, dilatation of the opposite pupil, 
and an accelerated action of the heart. Galvanization of the cervical 
sympathetic is much slighter and less certain. 

In the human subject, this is a most difficult procedure. The cervical 



ELECTBO-PHYSIOLOGY. 75 

sympathetic, being very deeply situated, lias in its close proximity 
the vagus, the carotid with its vaso-motor fibres, the base of the brain, 
the cervical region of the cord, etc. 

UPON THE SKIN. 

Galvanization of the skin will first produce pricking and burning 
(as detailed under its action on the sensory cutaneous nerves), rapidly 
followed by an intense hyperaemia at both poles ; this redness may remain 
for hours, and be marked by the presence of papules or wheals, and 
finally succeeded by desquamation of the epidermis. 

If the current strength be augmented, pallor of the surface is noted 
at the cathode, followed by a rosy redness ; the skin becomes infiltrated 
and surrounded by a deep border ; upon opening the circuit the redness 
persists. At the anode a pronounced scarlatinal color appears, the 
skin is not infiltrated but covered with small elevations ; upon opening 
the circuit, the redness persists for a long time, and is followed by 
desquamation. 

UPON THE HEAD. 

Vertigo is the earliest symptom manifested in galvanization of the 
head, when a strong current is passed transversely or in the antero- 
posterior direction (frontal bone to the back of the neck). The giddiness 
is most pronounced when the current is passed transversely. It has been 
maintained by some observers that ocular movements play a dominant 
part as a result of the severe vertigo, and that there is a disturbance of 
the muscular sense. With a strong transverse current passed through 
the mastoid processes, oscillation of the eyes occurs, the direction being 
that of the positive current. If the anode be on the left side, both eyes 
will be turned to the right. In some persons, galvanization of the head 
has resulted in nausea, vomiting, syncope, dulness or mental confusion. 

UPON THE SPINAL CORD. 

Large, flat electrodes should be placed upon the neck, very strong 
currents should be employed, and closure and opening should be resorted 
to. If the negative electrode be placed on the upper lumbar vertebrae, 
CaCl or change of polarity to Ca will produce vigorous contractions of 
the muscles supplied by the sciatic nerve, proving that the current has 
invaded the cord. 

UPON THE ABDOMINAL ORGANS. 

Vigorous faradization of the gall-bladder in cases of catarrhal jaun- 
dice, has caused the widely contracted gall-bladder to suffer a marked 



76 ELECTRO-THERAPEUTICS. 

contraction. Likewise in enlargements of the spleen, by direct faradiza- 
tion with large moist electrodes, or by employing two faradic brushes 
over the splenic area. 

The pharynx and the velum palati may be faradized and galvanized 
by applying the positive electrode on the upper posterior part of the 
neck, and by rapidly passing the cathode over the lateral surface of the 
laryngeal area. Contraction of the muscular wall of the esophagus can 
be obtained by introducing electrodes, similar in shape to oesophageal 
bougies. 

The stomach and intestines react to currents by slow contractions, 
which gradually spreading induces a peristaltic action. Faradism is 
more effective in these cases than is galvanism. 

Vigorous faradization of the abdomen is often associated with a 
gurgling sound, and with the production of visible, palpable peristaltic 
movements of the stomach and intestines. The digestive tract may be 
reached by one electrode placed on the back, the other stabile or slowly 
moving over the corresponding portion of the abdominal wall ; or by 
the introduction of an electrode into the stomach or into the rectum, the 
other being applied labile or stabile upon the external abdominal wall. 
Faradization of the bladder may be accomplished by introducing a 
urethral electrode as far as the vesical neck. Galvanic currents may 
likewise be employed. The contraction of the vesical sphincter and the 
urethral muscles is readily perceived. 

ELECTRICAL CURRENTS IN DISEASES. 

This is a most complicated process. Remak believed (and this 
view still obtains) that with the passage of the current there results a 
dilatation of the blood-vessels and lymphatics, causing an increased flow 
of blood and nutritive material, thereby favoring absorption of effete 
matter : that there is also an increased osmotic power of the tissues, 
changes in disassimilation and nutrition of the nerves, changes in the 
molecular arrangement of the tissues and the mechanical transportation 
of fluids from one pole to the other. To this series of changes the name 
' ' catalysis ' ' is applied. 

Electrical Sleep. 

To Stephane Leduc of Nantes 1 the medical profession is indebted for 
a comprehensive study of the so-called u electrical sleep," a state closely 
simulating chloroform narcosis and characterized by the same tendency to 
remain in any set posture, all movements save those of the heart and 
lungs being purely reflex in character. 

Leduc describes the procedure as an intermittent unidirectional 
current of low tension, in which the duration of flow and intermission are 
1 Archives of the Rontgen Ray, vol. xii, No. 2, July, 1907. 



ELECTRO PHYSIOLOGY. 77 

sharply defined and follow each other in absolutely regular succession. 
This state may be maintained for many consecutive hours, ceasing with 
the withdrawal of the current. 

A. ELECTRO-PHYSIOLOGICAL DATA. 

Of all the deep organs, the brain is the most responsive to electric 
currents. The current penetrates the brain by the shortest route through 
its thickness, in order to reach the nerve-centres, which are good con- 
ducting tissues ; the excitation results iii sensations of taste and light ; 
but one of the chief effects produced by the current as it passes through 
the head is vertigo, attaining its maximum when a continuous current is 
passed suddenly from one ear to the other. Electrical vertigo is always 
due to a variation in the intensity of current the more rapid the varia- 
tion the more marked the vertigo; also, the more transverse the direction 
of the current the more intense the vertigo. 

B. PRODUCTION OF ELECTRICAL SLEEP. 

In order to produce electrical sleep in animals, Leduc shaves the 
animal's head as far anterior as the eyes, and applies a thick piece of 
absorbent cotton- wool, soaked in a warm solution of chloride of soda, 
1 to 100 ; upon this wool is placed a metallic electrode of flexible tin, to 
which is soldered the conducting wire in connection with the negative 
pole ; the other electrode may be placed on any portion of the body on 
the same side. In order that the potential shall not vary, the head is 
connected to the negative pole. The current depends on the alterations 
of potential of the positive pole on the body, which is high when the 
circuit is closed and falls suddenly when the circuit is broken. Electrical 
sleep may be produced by connecting the positive pole to the head, but 
a greater intensity and greater energy are required and sleep is not so 
profound. The experiment being arranged, the potential is raised, at 
first more quickly, afterwards more slowly. In the first place, all the 
influences which suppress cerebral functions cause excitement, as is the 
case with alcohol, opium, etc. We may control the intensity of this 
excitement, in the slow and gradual raising of the potential and current. 
The addition of one volt in sixty seconds will produce sixty times less 
excitement than if it were done in one second. The excitement immedi- 
ately precedes the sleep, therefore the raising of the potential should be 
made more slowly as the potential itself increases. Without a cry the 
animal passes into a state of cerebral inhibition ; the reflexes are unaf- 
fected, especially if the spinal cord be not included in the circuit. In 
the rabbit, 6 to 8 volts are required, giving 1 to 2 ma. of interrupted 
current, corresponding to 10 or 20 ma. of the continuous current. At 
any moment the experiment may be stopped by suddenly withdrawing 
the current. The awakening is instantaneous, the animal exhibits 
neither pain nor fatigue ; on the contrary all of them, even after being 
operated upon, frisked about and ate readily. 



78 ELECTRO-THERAPEUTICS. 

It is interesting to note that Professors Malherbe and Rouxeau 
experimented upon Professor Leduc with a view to electrical inhibition. 
The current was supplied by a generator of small internal resistance and 
a potential of about 60 volts. The frontal electrode was in direct com- 
munication with the negative pole, while a larger electrode on the flank 
was connected to the anode. To diminish the sensibility of the skin and 
the resistance of the body it is always well, as a preliminary, to pass a 
continuous current of from 10 to 20 ma. for five minutes ; besides this, 
cerebral inhibition is more easily obtained. The sensation produced by 
stimulation of superficial nerves is readily borne and in time subsides. 
The face reddens, the muscles of the face, neck, and arms twitch slightly, 
and there are noted fibrilly tremblings and tingling of the extremities. 
The inhibitory action is first seen in the speech-centre, then the motor- 
centres are completely inhibited with absence of reaction to painful 
stimulations. There is no facial expression of suffering, the pulse 
remains unaltered, but respiration is slightly interfered with. 

Leduc remarks that when the current reached the maximum he 
heard, as in a dream, the voices of those around him, and was aware of 
his inability of moving and of conversing with his colleagues. He felt 
the contractions and twitchings of the upper arm, but the sensations 
were blunted like those of a benumbed limb. The most startling experi- 
ence is the successive disappearance of the faculties which Leduc asserts 
resembles a nightmare in which one feels in danger, yet is unable to cry 
out or move. It is to be regretted that Leduc' s colleagues in their several 
studies upon him failed at each stance to press the current far enough 
to produce total inhibition. In one experiment the electro-motive force 
was raised to 35 volts, and the intensity in the interrupted circuit to 4 ma. 
In two consecutive stances he remained for 20 minutes under the influence 
of the current. Upon opening the current, awakening was immediate, 
and Leduc remarked: i ' No after-effect was experienced further than a sen- 
sation of well-being. Immediately after the experiment, I gave an address- 
to a society of retired workmen of which I am an honorary member." 

C. LOCAL ELECTRICAL ANAESTHESIA. 

In most cases this is impossible, except where we are dealing with sub- 
cutaneous nerves having scarcely any motor-fibres, otherwise the muscles 
contract and these muscular contractions hinder local electrical anaesthesia. 

If we are dealing with a subcutaneous nerve, as has just been men- 
tioned (let us say, the median) , and if we place on the nerve at the wrist 
a small sponge electrode, forming the cathode of the intermittent current, 
a larger anode being placed on any part of the body, and gradually raise 
the intensity of the current, a tingling is produced at the finger-tips in 
the part supplied by this nerve. In this region sensation is so largely 
inhibited that with the eyes closed the patient cannot say definitely 
whether he is pinched, pricked, or cut. Local anaesthesia is comDlete- 



CHAPTER VIII 
PEACTICAL APPLICATIONS IK DISEASED CONDITIONS. 

I. Cutaneous Affections. 

To a very large extent electric currents have been employed in the 
treatment of skin diseases, and, as the technic differs greatly in numerous 
cutaneous affections, it seems best to enumerate the various skin lesions, 
detailing under each the technic that seems most applicable. 

ACNE. 

In this affection Liebig and Rohe have obtained favorable results. 
I have seen a few cases improve by the use of hyperstatic sparks, and 
in one or two instances by the ordinary breeze. 

ECZEMA. 

The local effect of the static current is specially indicated in eczema, 
where the brush discharge may be most advantageously employed. 
Eczema yields to electrical treatment more easily than any other skin 
lesion. Rockwell recommends the application of the galvanic current 
applied either locally or centrally. Bordier (quoted by Hedley) reports 
a case of eczema thus treated, the result being very satisfactory. He uses 
the positive breeze, and this frequently reversed. The hydro -electric 
bath has given very satisfactory results in the practice of Gautier and 
Laret. 

PRURITUS. 

In pruritus the electric breeze is most useful. The duration of treat- 
ment should be between fifteen and twenty minutes. The metallic point 
should be held 10 to 15 cm. from the part. 

ALOPECIA. 

Local galvanization and also the static breeze are often beneficial in 
some cases. 

SYCOSIS. 

M. Boisseau du Rocher employed the following method for sycosis. 
Ten to fifteen silver needles attached to the positive pole are inserted into 
different points, the indifferent electrode is applied to the nape of the 

79 



80 ELECTEO-THEEAPEUTICS. 

neck, current three to four milliamperes, duration about ten minutes, 
application every second day. By this means the oxy-chloride of silver 
is formed, which is diffused into the tissues by the current. It may take 
three or four weeks, and 20 to 30 seances, to complete an absolute cure. 

HYPERTRICHOSIS. 

Since we are able to cause a general or local epilation with the 
X-rays, the process of electrolysis is gradually being abandoned. The 
method with the electric needle, formerly so prevalent, but tedious and 
painful in operation, has largely given way to the X-rays. I have 
succeeded in removing hair from the forearm by a weak but constant 
current, but it never should be forgotten that an acute and active derma- 
titis may thus be readily produced. If the hairs are few in number and 
scattered over the face, I believe the electric needle safer and less dan- 
gerous though more painful than the Rontgen rays. On the contrary, a 
burn with the X-rays may leave a life-long scar. For the face, therefore, 
it is advisable to resort to electrolysis. 

The method of epilation is as follows : Place the patient on a high 
chair, take a fine needle which is attached to the negative pole of the 
galvanic current, while the patient holds the positive pole in the hand. 
A sponge of fair-sized dimensions and well wetted is attached to the latter 
electrode. The number of cells used is 5 to 8, so that a current of from 
3 to 4 milliamperes is produced. A current of smaller amperage than 
this may be used ; 1 to 2 milliamperes being often sufficient. The hair 
is seized with a pair of tweezers, at the same time the disengaged hand 
inserts the needle slowly into the hair- follicle. The patient squeezes the 
sponge to complete the circuit, which is indicated by small bubbles 
emanating from the point where the needle is inserted. The needle is 
usually allowed to remain 10 to 15 seconds. The patient now loosens the 
hold so as to break the circuit. An interrupting handle (Fig. 46) is 




FIG. 46. Interrupting needle-holder for electrolysis. 

employed by many for this particular purpose. If the hairs are not 
loosened readily, defer the procedure until another time. The needle 
should be heated to redness, when its repeated introduction will 
be necessary for each individual hair. This method is for coarse hair. 
For the downy hair seen on the lip or chin in women, this method is 
unsatisfactory, and it is advisable to resort to the X-rays. 



APPLICATIONS IN DISEASED CONDITIONS. 81 

PSORIASIS AND PITYRIASIS. 

In both of these diseases, the negative pole of the galvanic current 
seems to be the more efficacious. Sometimes both poles, bearing large 
electrodes, are employed. 

RINGWORM AND SCLERODERMA. 

Both of these diseases are markedly improved and often cured by the 
application of the galvanic current. 

PRURIGO. 

Dry faradization may give relief from the intense itching, and at 
times will effect a cure. 

CUTANEOUS ANAESTHESIA. 

For this condition Rockwell believes faradization to be a specific. 
The electric brush should always be given a trial. 

HERPES ZOSTER. 

Dr. Larat 1 reports several cases of acute herpes zoster in the erup- 
tive stage with fever and unbearable lancinating pains, which were cured 
by the continuous current. The method is simple and can be employed 
by any physician owning a galvanic battery. The positive pole (repre- 
sented by an electrode 3}4 by 5 inches [9 x 13 cm.], covered with absorb- 
ent cotton and well moistened) is applied over the point of emergency 
of the affected nerve or nerves. The negative pole is connected to 
an electrode placed over the affected area. The absorbent cotton cover- 
ing the electrode should be made large enough to cover all the vesicles, 
whether formed or forming. A current strength of from 6 to 10 ma. is 
employed for 25 or 30 minutes. The sensation produced by this current 
is that of a severe pricking, but it is well borne by the patient. 

Two applications are made daily, but in case of failure at first, the 
author recommends that more be used. Under their influence the pain 
ceases, the eruption is arrested, the vesicles show a tendency to dry up, 
in fact all the local manifestations of the disease appear aborted. A 
cure is accomplished in from 24 to 48 hours, unattended by the usual 
subsequent neuralgia. 

The probable explanation of these good results, is the accepted hy- 
pothesis, that herpes zoster is a trophic and sensory peripheral neuritis, in 
which the continuous current has the same curative effects as are L*anifest 
in other forms of peripheral neuritis. 

1 Revue Internationale d'^lectrotherapie, October, 1904. 
6 



82 ELECTRO-THERAPEUTICS. 

NJEVUS. 

Electric treatment should be instituted as soon after birth as is prac- 
ticable. The needles may be alternately negative and positive, or all 
attached to one pole, and an ordinary pad electrode used for the other 
pole. Current may be employed up to 30 ma. Duration 5 minutes. 
Current must be gradually lowered to zero before withdrawing the 
needles. 

PORT- WINE MARK. 

For these disfigurements use a number of needle-points attached to 
a disk, so that punctures may be effected simultaneously ; the current is 
gradually turned on, allowing 2 to 3 ma. for each needle. This proced- 
ure is to be repeated every 3 weeks. The needles should be insulated, 
except at the point. The pole selected will vary with the vascularity, 
the prominence, and the extent of the nsevus. With large blood channels 
use the positive pole; for flat spots some of the needles may be positive, 
some negative. Current 30 ma. Duration 10 to 15 minutes. The 
needles are left in place half a minute, so as to produce a slight eschar, 
they are then shifted ; the whole surface being thus dealt with. 

MOLES AND WARTS. 

The indifferent positive electrode is placed in the neighborhood of 
the growth. A needle attached to the cathode is inserted at its middle, 
or just above its base, parallel to the integument. Current about 5 ma. 
Allow the current to flow till the growth changes color and resembles a 
cluster of herpes. Then bring the current to zero. Time required is 2 
to 3 minutes for each wart. In a fortnight the growth disappears, 
no scar remaining. Another method is to attach both poles to sharp 
needles and transfix the growth by the needles inserted parallel to the 
skin. 

FURUNCLES AND CARBUNCLES. 

The local treatment of these growths by electricity is advocated by 
Marcus. 1 Previous to the appearance of suppuration, he opens the folli- 
cles of the affected area and introduces into them an epilatiou needle con- 
nected with the negative pole. Through this, a current of one to two 
milliamperes is passed at first, which is afterwards increased to ten. By 
slightly moving the needle around, the opening of the follicle is consider- 
ably enlarged, and a quantity of frothy serum is soon poured out, con- 
taining portions of tissue and numerous cocci. Then the needle is 
removed and the spot is carefully cleansed ; the needle is again introduced 

1 Miinchener medizinische Wochenschrift, May 23, 1905, No. 21. 



APPLICATIONS IN DISEASED CONDITIONS. 83 

and one or two milliamperes of current are again allowed to pass. The 
positive pole is now to be connected with the needle, and the current again 
raised to ten milliamperes. This causes the liberation of acid, which is 
always more energetic in its nascent condition. In two or three minutes 
the treatment is suspended and the surface again washed with water. 
Each affected follicle is treated in the same manner. If suppuration 
has already commenced, a larger needle is introduced into the folli- 
cles and moved around, until the entire greenish-yellow pus plug is 
broken up and disappears in foam. Then the positive pole is intro- 
duced and is again followed by the negative pole. A wet dressing is 
applied. This treatment is not applicable to very large carbuncles or 
extensive swellings. 

II. Muscular System. 
MYALGIA. 

Employ local faradization with a mild current, either stabile or 
labile. Stabile galvanization with a mild current is often effective. Do 
not cease if the condition is unaffected or aggravated at first, but continue 
the applications. Static electricity by means of a roller electrode (Fig. 47) 
or general frankliuizatiou is frequently curative. 




FIG. 47. Roller electrode with insulated points for muscular faradization. 

When employing the battery, Erb advises that a current up to 20 
ma. may be used, applying the anode to the painful parts, and the seance 
terminated by a few reversals. 

General electrization by means of the monopolar sinusoidal bath, 
faradic current applications, and static friction have also many advocates. 

WRITERS' CRAMP. 

It is assumed that this disease is due to a weakness of the central 
nervous system. General galvanization of the spinal column and pe- 
ripheral nerves should be resorted to. Faradic electricity is useful when 
applied directly to the muscles or groups of muscles of the hand and 
forearm. Seen in the very beginning, its course is often arrested by 
using the above forms of electricity. 



84 ELECTBO-THERAPEUTICS. 

Weiss l recommends the use of constant currents of 2 to 5 or 8 ma. 
for 15 to 25 minutes, with absolute rest from writing. Applications 
twice daily should be employed during the first weeks, diminishing later 
to 2 or 3 times a week. If extension is the chief symptom, the anode is 
to be applied to the palm ; if flexion be marked, place the positive pole 
to the dorsum of the hand. Apply the cathode to the nape of the neck 
or the upper, inner surface of the arm and the anode to the sensitive 
parts for 10 to 20 minutes. Treatment should also be applied to the 
motor cortex and to the lower cervical region of the spine. 

TORTICOLLIS. 

In torticollis galvanization of the muscles of the affected side with 
currents of from 5 to 15 ma. , and faradization of the muscles of the 
opposite side often prove most efficient. Galvanization of the sympa- 
thetic and the upper portion of the spinal cord should always be tried ; 
but long-continued applications are contraindicated- 

MUSCULAR CONTRACTIONS. 

These may arise in hysteria, myelitis, meningitis, Pott's disease, or 
they may be reflex. These affections may be treated by galvanization of 
the affected muscles or of the antagonistic muscles with stabile currents, 
or by galvanization of the head, spine, or sympathetic, etc. 

SECONDARY CONTRACTURES OCCURRING IN HEMIPLEGIA. 

Charles S. Potts 1 claims that in cases of hemiplegia where con- 
tractures have been allowed to develop, the patient's disability proceeds 
more from the deformity so produced than from muscular weakness. As 
the deformity is caused by the overaction of one set of muscles, usually 
the flexors, and is only aggravated by their stimulation, the indications 
are for measures which tend to relax the contracted muscles. This can 
be effected by the application of the positive pole of a galvanic current 
over the motor points of the affected muscles, and the indifferent elec- 
trode (negative pole) to any part of the sound limb, as over the sternum, 
or to the nape of the neck. Anelectrotonus should be aimed at. The 
current employed should be gradually increased from to 5 or 10 milli- 
amperes (about as much as the patient can bear), and kept at this maxi- 
mum for five minutes, then gradually reduced to zero. Unless the 
current is gradually reduced to zero, catelectrotonus will follow and the 
condition of increased irritability thus set up will prevent the accomplish- 
ment of our object. After these applications of a continuous current, a 

1 Centralblatt fur die gessam. Therap., April, 1891. 

1 University of Pennsylvania Medical Bulletin, October. 1905. 



APPLICATIONS IN DISEASED CONDITIONS. 85 

weak faradic current should be employed, just strong enough to cause the 
muscles to contract moderately, about a dozen times and no more, as over- 
stimulation defeats the end we have in view. The method is also of 
service as a preventive ; it may be started any time after the end of the 
second week following the seizure. Three treatments a week for several 
months should be given, followed by an interval (several weeks) of rest. 

MYASTHENIA GRAVIS. 

When tetanized by the interrupted current, the myasthenic muscle 
shows a rapid decrease in the degree of response to the current, evincing 
the normal physiological effect of fatigue with excessive and abnormal 
rapidity ; but after tetanization it remains just as responsive to a single 
closing shock, proving that the muscle is not diseased, but that the 
trouble resides in the nervous system. 

III. The Articular System. 
SYTSTOVITIS. 

In acute synovitis all forms of electrical applications are contraindi- 
cated. Subacute and chronic synovitis will be benefited by galvaniza- 
tion or faradization. When a cure cannot be effected by these means, 
the application of percussion static sparks is sometimes effective. 

HYDRO- ARTHRITIS. 

In the acute stage, as in synovitis, any form of electricity is irritat- 
ing. In the subacute and chronic forms the active electrode (negative) 
of 20 to 25 ma. current should be employed. Each treatment should last 
no longer than 10 to 15 minutes. The indifferent electrode is placed on 
the back of the patient. The treatments should be made on alternate 
days, or every third day. 

RHEUMATOID ARTHRITIS. 

In this affection the sinusoidal bath is very beneficial. Dr. Eoques l 
treats the affected joints by the electrolytic introduction of ions of 
salicylic acid into the surrounding tissues. Many electro -therapeutists 
believe that the beneficent action thus obtained is partially ascribable to 
a nutritional change in the diseased area. 

CHRONIC ARTICULAR EHEUMATISM. 

Chronic or subacute articular rheumatism frequently yields to static 
or galvanic treatment ; with the former it subsides gradually. The 

1 Arch, d' Electricity medicate, 1903, page 689. 



86 ELECTEO-THERAPEUTICS. 

condition will usually be benefited by local faradization. In very acute 
and painful cases, it is well to resort to anaesthetization with cocaine 
by the cataphoric process. 

GOUT. 

This disease is benefited by static electricity. This stimulates all 
the tissues of the part, improving the circulation, and in general doing 
much good. The continuous flow of current has been recommended, but 
I have failed to obtain any appreciable result from its employment. 
Lithium dipolar baths are prescribed by some authorities. 

Guilloz l reports two severe cases of gout treated by monopolar elec- 
tric baths containing lithium carbonate. He recommends currents up 
to 200 ma. , and places the positive pole in the bath, the cathode of large 
size is applied to the patient's back. Similar reports by Bordier, in the 
same journal, are recorded. 

It is usually maintained that the various currents applied directly to 
the joints will cause a stimulation of the tissues of the part, resulting in 
an absorption of the urates. Prolonged applications may aggravate the 
condition. 

TUBERCULOUS ARTHRITIS. 

Chanoz and Leveque 2 report three cases, where the direct current- 
proved of inestimable value in tuberculous arthritis. In one case LeVeque 
himself was the sufferer, and his treatment directed to his own person 
was eminently satisfactory. He believes that the negative pole is effec- 
tive for relieving the superficial pain, the deeper parts being more 
influenced by the anode. The current should range from 25 to 50 ma. ; 
the electrodes should be of large size and placed on either side of the 
diseased joint. 

FIBROUS ANKYLOSIS. 

Apply large electrodes moistened in a solution of sodium chloride to 
each side of the joint. The negative pole should be placed nearest the 
joint. Use a current strength of 25 to 35 ma. Duration of each treat- 
ment from 10 to 25 minutes. Treatments 2 or 3 times a week. These 
electric treatments should be instituted only when there is no inflamma- 
tory process present. 

M. A. Zimmermann 3 has reviewed the medical literature, and with 
the exception of a case treated by Leduc, of ankylosis of the elbow-joint 

1 Arch.d'6lectricite medicale, June, 1899. 

2 Arch. d'Electricite mSdicale, 1903, page 264. 

Revue Internationale d'Electrotherapie, October, 1904. 



APPLICATIONS IN DISEASED CONDITIONS. 87 

reported cured by electricity, he has found nothing on the subject. Many 
surgeons recommend electricity in such cases for its action on the mus- 
cles surrounding the affected joints, but that is a form of electrical mas- 
sage, and not an electrical application. Zimmerinaun has obtained good 
results, both in hospital and private practice, in cases of fibrous anky- 
losis, without pain or discomfort to the patient, by the employment of the 
continuous current. It is of importance to determine the nature and 
severity of the affection, because in cases of bony ankylosis no more 
good is accomplished by electricity than with other forms of treatment. 
However, in some cases, severe fibrous ankylosis in which massage and 
passive motion failed to afford relief, some degree of mobility was 
obtained ; whereas in adhesions resulting from a gouorrho3al or other 
arthritis or from prolonged immobilization, cures were speedily attained. 
It should never be forgotten that radiographs are of inestimable value 
in making a differential diagnosis. The negative electrode should be 
placed over the most superficial part of the diseased joint, and the posi- 
tive electrode on the part of the joint directly opposite, so that the lines 
of flux will pass in a straight line through the joint. The maximum 
intensity should be at least 40 ina. , and the applications made every other 
day. 

The number of applications necessary to effect a cure will depend 
upon the severity and chronicity of the affection ; from 15 to 20 
applications are required in cases of moderate severity. 

IV. Digestive System. 
VOMITING. 

According to Apostoli and Bordier 1 two electrodes, each 2 cm. in 
diameter, are attached to the positive pole of the battery, and are placed 
over each pneumogastric nerve, between the insertions of the steruo-cleido- 
mastoid muscle. The indifferent electrode (100 sq. cm.) is placed upon 
the epigastric region attached to the negative pole. The strength of 
current should be from 5 to 10 milliamperes. If nausea is threatened, 
the current must be at once run up to 15 or 20 milliamperes and there 
maintained, so long as any ill effects are experienced by the patient. The 
duration of the stance varies from 4 to 20 minutes. Two sittings a day 
may be required at the beginning of the treatment. 

DILATATION OF STOMACH. 

Dilatation of the stomach is best treated by the static induced cur- 
rent. The outer cover of the Leyden jar is attached to an ordinary 
exciter, terminating in a small ball. This is applied over the uncovered 

1 Therapeutic Electricity, quoted by W. S. Hedley. 



88 ELECTRO-THERAPEUTICS. 

epigastric region ; the distance of the pole of the machine should be 
such as to produce sparks at the rate of from 10 to 15 per second. The 
exciter is to be left on one spot for a couple of minutes, then displaced to 
another, and so on. 

The duration of each treatment should be from 10 to 15 minutes ; 
the usual requisite number of sittings is from 18 to 20, which should be 
given every second day. 

NERVOUS DYSPEPSIA. 

For this affection the galvanic current does most good. 

The negative pole is usually placed over the epigastric region and 
the positive pole opposite the lumbar region. The strength of the cur- 
rent should be from 30 to 40 milliamperes ; the duration of each treat- 
ment should be from 10 to 15 minutes : the number of treatments to bring 
about relief is from 8 to 10. A cure cannot be effected by this method 
of treatment. 

CONSTIPATION. 

In these cases, applications over the cord or the sympathetic system 
frequently produce most excellent results. Direct action on the digestive 
tract is often advantageous in promoting peristalsis. 

Method of Application. The patient is placed on the insulated plat- 
form, and the indirect static spark is applied to the various parts of the 
abdomen. This should be done by starting in the right iliac or inguinal 
region, gradually ascending to the liver, thence across the upper abdomen 
along the course of the transverse colon. This is followed by descending 
to the left side of the belly toward the upper part of the rectum. The 
object is to excite peristalsis in the normal direction. 

The galvanic current is also applied for this condition, but in my 
experience the results obtained are not so satisfactory as with static 
electricity. A large-sized electrode (100 sq. cm.) is attached to the 
negative pole of the battery, and the electrode is applied to the belly in 
a similar manner as outlined above. The indifferent positive pole is 
applied to the lumbar spine. The faradic current may be applied instead 
of the galvanic. 

Dr. Wahltuch 1 has reported seven cases in which the continuous 
current produced good results. He used a large sponge for the positive 
pole and an ordinary medium-sized one for the negative. The former 
he applied to the epigastrium, while the latter was slowly moved over 
the whole abdominal surface. The current was from 5 to 30 milliamperes. 
The operation was repeated on alternate days, from three to six weeks. 

1 British Medical Journal, 1883, vol. 11, 623. 



APPLICATIONS IX DISEASED CONDITIONS. 89 

A method, which has become popular in France, is the introduction 
into the rectum of a bougie electrode, the other pole being kept on the 
abdomen. To avoid the risk of electrolysis, and injury to the rectal 
mucous membrane, a combined douche and electrode has been devised. 

ENTERITIS. 

Dr. Zimmern 1 describes the excellent results he had obtained in 
mucous membranous enteritis by the use of the galvanic current applied 
externally to the abdomen. The treatment consists in applying the two 
electrodes in the right and left iliac fossa3, and using a current which 
starting from is slowly and gradually brought up from 60 to 150 mil- 
liamperes, then as slowly again reduced to 0. The direction of the cur- 
rent is then reversed. Each treatment lasts about 20 minutes, and is 
repeated three or four times a week. No special attention is paid to 
the diet, though highly spiced food is of course forbidden. All enemas 
or cathartics are strictly prohibited, save with the following exceptions. 
If there is much constipation, two spoonfuls of castor oil are given every 
five days, or a large lavage of the intestine is to be practised if the castor 
oil does not produce the desired effect. Every day a very small enema 
of cold water (100 grammes) is given so as to start defecation reflexly, 
which is more or less dulled by the lack of sensibility of the mucous 
membrane. 

According to Zimmern, the results obtained are not so much due to 
action on the muscular coating of the intestine as to action on the general 
circulation of the intestine. Out of 30 patients treated in this manner 
only 2 were refractory to the treatment, and 20 were absolutely cured, 
the remaining eight were only ameliorated. Dr. Delherm, another 
specialist in this line, describes the results obtained by the galvano-faradic 
treatment in 53 patients : 46 cases were very much ameliorated by the 
treatment, and 36 remained cured after a year. 

Rene Desplats, in a communication to the Societe des Sciences Medi- 
cales, 1 stated that he had successfully treated twenty-five cases of muco- 
membranous colitis and spasmodic constipation by electricity of high 
voltage. 

His method consists in placing two large metallic electrodes (tin 
plates, eight by ten centimeters) covered with several double folds of 
buckskin, moistened with warm water, upon the surface of the abdomen, 
one in each iliac fossa, and passing for ten minutes a current of sixty to 
seventy milliamperes. a little more or less, according to the tolerance of 
the patient. He also reverses the current at the end of each minute. If 
the sudden reversal causes too great a shock, he lowers the current even 

1 La Presse Medicale, No. 27. 

2 Journal des Sciences Medicales de Lille, April 14, 1906. 



90 ELECTKO-THEBAPEUTICS. 

to zero before reversal. The resort to all purgative remedies is suspended 
during the treatment (which is repeated every two or three days), but 
if there is no spontaneous movement by the third day, he orders an 
enema, and this is gradually reduced. In atonic constipation the results 
were very satisfactory, even in children. 

M. W. Peyser ' employs a short, soft-rubber rectal tube in which is 
placed a metallic conductor ; this is passed into the rectum, coiling in the 
ampulla being prevented if possible. The metallic conductor is attached 
to the positive pole. The tube is connected with the tube of a fountain 
syringe which contains saline solution. A large pad electrode, well 
moistened with saline solution or thoroughly soaped, is attached to 
the negative pole. While the solution is flowing, or after the syringe 
is emptied, the current is turned on and gradually increased in strength 
till from 15 ma. to 20 ma. are passing, or till the patient complains of 
burning at the negative pole. There should be no sensation from the 
current at the positive pole. The solution in the bowel acts as one of the 
terminals, thus spreading the current over a large extent of surface and 
permitting more current to be used. Similarly, the large pad permits 
increased amperage. In a varying period of time desire for defecation 
comes on sometimes immediately, sometimes not for several hours. 
Should it come immediately, the patient should be persuaded to endeavor 
to continue the treatment for a while longer. The number of treatments 
required varies from six to ten, rarely less than the former or more than 
the latter. The tolerance of the patient should be the standard as to the 
quantity of current, some taking 20 ma. even at the first treatment, 
others never being able to take more than 12 ma. at any. The time of 
each treatment should be from fifteen to twenty minutes, seldom more, 
repeated daily till positive effects are obtained, and then at lengthening 
intervals till success is assured or failure manifested. 

FISSURE OF THE ANUS. 

The indifferent electrode is placed upon the abdomen, while the 
anode, covered with absorbent cotton saturated with a 10 per cent solution 
of cocaine (Massey), is applied to the fissure, using a 1 to 5 ma. current 
for several minutes. 

AFFECTIONS OF THE BECTUM. 

In paresis of the sphincter and in prolapse, the use of the faradic 
current has produced most successful results. 

Dr. G. Betton Massey 2 treated a case of rectal prolapse in a middle- 
aged woman, by placing a felt-covered, flat electrode under the sacrum ; 

1 Virginia Medical Semi-Monthly, Feb. 9, 1906. 
* Therapeutic Electricity, W. S. Hedley. 



APPLICATIONS IN DISEASED CONDITIONS. 91 

the patient being in a dorsal position. An ordinary rectal electrode was 
inserted into the rectum, connected with the positive pole. With the 
proper regulation of the current, slow interruptions were effected, by 
touching one of the terminal posts with the tip of the conducting cord. 
This produced a good form of muscle contraction. Duration 10 minutes. 
No prolapse occurred after the first treatment. 

HEMORRHOIDS. 

The treatment of internal and external hemorrhoids by electricity is 
by no means easy. I have never seen any good accomplished by this 
agent, except in those cases where the electric current was employed 
cataphorically. Some have suggested the use of electric needles, and 
one or two succeeded in obtaining very satisfactory results. The electric 
cautery, of course, is a method for the relief of piles ; the procedure is 
rapid, aseptic, and painless. 

STRICTURE OF THE KECTUM. 

The treatment of rectal stricture with electricity is identical with that 
of stricture of the urethra. The instrument used is larger (Fig. 48), and 




FIG. 48. Double rectal bulb electrode. 

should also have a flat surface in front or below. The indifferent elec- 
trode should be held by the patient's hand, or it may be applied to the 
anterior abdominal wall. The strength of the galvanic current should be 
from 5 to 15 milliamperes. 

V. Genito-Urinary System. 
STRICTURE OF THE MALE URETHRA. 

Crussel, in 1839, was the first to employ electrolysis for the cure of 
stricture of the urethra ; Mallez and Tripier were the first to practise it 
systematically. 1 

Dr. W. E. Stevenson 2 asserts that : The electrodes for this purpose 
are catheter-shaped gum-elastic bougies, terminating in a metal nickel- 
plated piece connected to a binding screw on the handle. Place the 
indifferent electrode on the patient's back ; the metal plate is made 

/"De la garrison durable des r^strecissements de 1'urethre par la galvano- 
caustique chimique," Paris, 1867. 

2 Annual Meeting of the British Medical Association, 1886. 



92 ELECTRO-THERAPEUTICS. 

positive. Estimate the distance of the stricture from the meatus, by 
marking on an ordinary bougie which has been passed. Suppose this 
bougie was a No. 3 (English). A No. 5 electrode is passed down to 
the stricture, where it is arrested. Corroborate this by previously mark- 
ing the electrode, corresponding to the mark made on the bougie. Place 
the electrode again in position, connect it with the negative pole ; the 
circuit is closed, and the current gradually increased without breaks, 
until the maximum strength is reached, about 5 or 6 milliamperes. The 
electrode is gently pressed against the stricture in the normal direction 
of the urethra until, from the dissolution of the obstacle in front of it, 
it passes into the bladder. The current should at once be cut off, and 
the bougie withdrawn. 

The late Dr. Robert Newman, of New York City, advocated the 
following : The patient is placed in the dorsal position, the thorax, 
abdomen and lower extremities being in one horizontal line, while the 
head of the patient is slightly elevated by raising the head-rest of the 
table. A large electrode in the terminal, on the positive side of the 
battery, is placed over the abdomen in a fixed position, and well pressed 
upon the tissues, so as to make a perfect circuit. 

The negative electrode, in the form of a whalebone bougie, has at 
the inner extremity an olive-shaped head of the proper size. This is 
introduced into the urethra as carefully as possible. The current is then 
turned on with the lever of the rheostat, so as to prevent shocking the 
patient. 

The galvanic current that is used usually varies between three and 
five milliamperes. The treatments should last for a period of from 10 to 
15 minutes. Two of these treatments are essential to start with, then 
discontinue for another period of two days or two weeks, according to 
the indication. Care should be exercised to pass through the lumen of 
the stricture a bougie of very little larger dimensions than that of the 
calibre of the opening. At the second treatment a bougie with a 
metallic ovoid should be passed, the dimensions of it being slightly larger 
than that used primarily. By doing this, there is a gradual dilatation of 
the lumen. After two weeks a bougie of little longer dimensions should 
be employed, and exactly the same process carried out as outlined above. 
The treatment should consume a little more time, and the current used 
should be 5 milliamperes. The third treatment should be given on the 
16th day, the fourth on the 19th, and so on. The operator should always 
remember that in active inflammation of the urethral tract, electric 
applications are contraindicated. 

After the dilatation of the stricture, 1 Selhorst inserts an Ober- 
Isender's urethroscopic tube, passing along the whole length of the 

1 British Med. Journal, March 24, 1906. 



APPLICATIONS IN DISEASED CONDITIONS. 93 

stricture. In examining the urethra, the tube is withdrawn slowly until 
the surface of the constriction is shown in the opening. The needle, 
ending in a strong platinum point from 1.5 cm. to 2 cm. in length, iso- 
lated quite close to its point, is forced to a depth of from 0.5 cm. to 
1 cm. into the fibrous tissue, according to the dimension, thickness, and 
hardness of the stricture. The needle is the negative pole of a galvanic 
battery, the positive pole of which, a large moistened disk, is placed 
on the thigh or on the abdomen. The electric current, of from 4 to 6 
milliamperes, is turned on for three minutes. Before withdrawing 
the needle Selhorst interrupts the current, and drives the needle into 
another part. This operation may be repeated four or five times during 
a sitting, and if executed by an expert hand, is said not to be very pain- 
ful. During the whole period of treatment a bougie is introduced once 
weekly, followed by an irrigation with a nitrate of silver solution to pro- 
mote reabsorption, and to maintain the passage of the urethra at the size 
required. 

Philippe 1 credits electrolysis with many cures of simple stricture, 
but maintains that a combination therewith of lavage with carbonic acid 
is required when chronic urethral inflammation exists as a complication. 
He records excellent results in varicose ulcers, torpid wounds, fistula, etc. 
The gas is heated to 45 C. and driven into the urethra under a pressure 
that may be regulated. It is saturated with essence of cinnamon as an 
antiseptic agent. Minet and Aversenq use rigid bougies with a mercury 
bisulphate battery. A current of 3 to 4 milliamperes is passed for a 
period of 15 minutes, once weekly. This treatment is preceded by 
progressive dilatation with ordinary sounds, but the permanent results 
are mainly attributed to the electrolysis. 

PROSTATITIS. 

This condition may be treated with local faradization or galvaniza- 
tion. One of the poles is applied to the urethra or to the prostate 
through an insulated sound or catheter. The other electrode is in the 
form of an insulated rectal sound. The terminal of the electrode passed 
into the urethra is of course allowed to remain uncovered, as it is to 
come indirectly in contact with the prostate. The current should be of 
such a strength as to produce a sensation of warmth in the deep urethra. 

Dr. John V. Shoemaker, 2 of Philadelphia, has devised an electrode 
which is well adapted to prostatic work. The instrument (Fig. 49) is for 
use in the reduction of hypertrophy of the prostate by means of the gal- 
vanic current from the negative pole. The usual flexible rheophores are 

1 La Presse Medicale. May 11, 1904. 

2 The Times-Register, January 17, 1891. 



94 ELECTRO-THERAPEUTICS. 

attached to the terminal binding posts (the negative pole of the battery 
being associated with the handle N, and the positive pole with the handle 
P). The reophores having been thus previously fastened, the rectal limb 
of the instrument (which has a movement in the vertical plane) is pressed 
down toward the sponge -covered moistened pole ; the olive-shaped bulb 
pole, B, having been previously slightly oiled. The instrument is then, 
with the handle N held in the rear, passed under the crotch. The cur- 
rent of the battery is supposed to have been previously set flowing. 
Grasping then the rear handle, N, with the right hand, and allowing the 
front handle, P, to fall away from the crotch, the patient now presses the 
olive-shaped bulb, B, gently into the rectum; any slight error of judg- 
ment as to direction being compensated for by the movement of that 
limb in the vertical plane. The patient then grasps the front handle, 




FIG. 49. Shoemaker's prostatic electrolyzer. 

P, and raises the lever formed by the hinges, H, thus bringing the mois- 
tened sponge-covered positive pole, S, in contact with the perineum. By 
exercising more or less pressure with this pole against the perineum, the 
current is then regulated to the greatest nicety by the patient's 
sensations. 

The resistance to the current varies from 25,000 to 30,000 ohms, the 
milliamperemeter indicating from 2 to 3 milliamperes, the duration of 
administration being, according to Dr. Shoemaker and other authorities, 
from 3 to 5 minutes. 

PARALYSIS OF THE URINARY BLADDER. 

The electrical treatment for paralysis of the bladder is divided into 
the internal and the external. The currents employed are both the gal- 
vanic and faradic. Some suggest the use of the static current, but in my 
experience this has accomplished little good. 



APPLICATIONS IN DISEASED CONDITIONS. 95 

The external application is conducted by placing the negative pole 
or electrode over the symphysis pubis, and the positive to the back of 
the neck. 

The internal application can be made by placing the insulated cathe- 
ter electrode or Duchenne's double vesical electrode into the urethral 
tract. The negative pole of the battery is attached to the leader in the 
rubber catheter, while the positive pole is applied to the hypogastric 
region, or back of the spine. 

INCONTINENCE OF URINE. 

This condition is treated electrically, as in paralysis of the bladder. 
In the adult, both the internal and external methods may be employed. 
In children the external method alone is usually used. 

Faradic treatment is to be preferred in cases of children and 
especially in those who have had incontinence from earliest infancy. Of 
40 subjects, 55 per cent, were cured by Genonville and Coinpain j 1 63 per 
cent, of the children were between 6 and 12 years old. The sittings 
numbered from 5 to 8 in congenital cases, and in non- congenital cases 
from 6 to 16 treatments, with the exception of 5 patients, who had 20 to 
29 seances. Slight improvement during the first week is a favorable 
sign. The current may be applied directly to the sphincter or to that 
immediate region. All but 20 per cent, of the subjects were improved 
or cured, and in 16 cases a complete recovery occurred in a maximum of 
16 visits. 

Nocturnal Incontinence. In this affection, the application of elec- 
tricity stimulates the cerebral and spinal centres, by producing painful 
local impressions, which tend to bring the inhibitory cerebral mechanism 
into closer relation with the reflex centres in the lumbar cord. For 
women and older girls, a bare metal sound is introduced into the urethra 
as one electrode, the indifferent electrode being placed upon the lower 
dorsal spine. The sound must not enter the bladder for more than a 
short distance, or else the current will pass to the urethral walls. For 
male patients the applications can be made to the perineum. 

SPERMATORRHOEA AND SEMINAL EMISSIONS. 

These conditions can be treated either by the application of local 
or general galvanic or faradic currents, either internal or external. The 
internal method consists of introducing an electrode, insulated by a rub- 
ber catheter, into the urethral tract, as outlined in cases of prostatitis. 
In the treatment of vesiculitis or ordinary spermatorrhoea, care must be 
exercised to cause as little irritation internally as possible. The results 

1 La Presse Medicale, 1904, No. 38. 



96 ELECTRO-THEEAPEUTICS. 

obtained are due to the electrolytic action on the mucous membrane, as a 
result of the mechanical pressure of the catheter, or upon a combination 
of these two factors. Sparks and the static breeze to the perineum, also 
the brush discharge over the lumbar and sacral vertebrae, may prove 
useful in some of these cases. 

IMPOTENCE. 

If this condition is the result of an organic lesion, electricity 
will do little good ; on the other hand, benefit may be gained by the use 
of the static breeze, spark, etc. Cases of impotency due to a psychical 
influence may likewise be improved by the use of electricity. 

ORCHITIS. 

Scharff 1 employed electricity successfully in the treatment of epi- 
didymitis. During the acute stage he applies the anode to the lower 
part of the scrotum with the patient in the dorsal position, employing a 
large electrode with a maximum current of half a milliampere ; dura- 
tion of the first application three minutes ; very gradually increased to 
five, and later to ten minutes. About the seventh day the current can 
be increased to three milliamperes. The cathode is placed over the 
groin and on the abdominal wall. The advantages of this treatment 
are its rapidity, and the early relief from pain and swelling. Good 
results have been obtained by Onimus and Duboc, of Eouen ; 2 Picot, of 
Tours, has succeeded in forty cases. 

NEPHRITIS. 

Rockwell reports five cases of nephritis treated by electricity, four 
of which recovered. Treatment covered a period of from two to eighteen 
months ; after a few months oadema and ascites disappeared. 

The technic of treatment consists in the employment of a high-ten- 
sion faradic current, and also the use of the static wave current, the 
latter being the more preferable. He suggests that these currents should 
be employed alternately. 

VI. The Nervous System. 
NEURALGIA. 

Electricity is applied to neuralgia in the following forms : 

General faradization and central galvanization. 

Local faradization or galvanization. 

Central and peripheral, or a combination of both. 

1 Centralbl. f. Krankh. d. Harn und Sex. Organe, 1, 1894. 
'Arch. d'felectricite' medicale, 1894. 



APPLICATIONS IN DISEASED CONDITIONS. 97 

Galvanization of the cervical sympathetic. 

Cataphoresis. 

The sinusoidal current. 

Electric brush. 

Electric moxa. 

Static electricity. 

Electric bands and disks. 

The magnet. 

The initial applications should be mild, owing to the pain frequently 
becoming intensified, especially after prolonged sittings. The applica- 
tions should be made daily, or every other day. Either the positive or 
negative pole may be applied over the painful points. There is no rule 
for the direction of the current. The duration of the seance should be 
brief. 

Should the faradic current be tried without effect, resort should be 
made to the galvanic current, or the two may be used alternately. Cen- 
tral and general galvanization are to be conducted on general principles. 
Cataphoresis will at times benefit, when other methods fail. The 
sinusoidal current often acts most happily. The electric moxa is some- 
times efficacious, but its use is attended with great pain. It acts partly 
as a counter-irritant. 

Cephalalgia. Dry faradization with the hand is most useful in many 
forms of headache. Stabile galvanization or faradization, uniform or 
increasing, may be used. General faradization is more effective than 
local applications. Central galvanization is at times the only effective 
measure. 

Tic Douloureux. In this exquisitely painful condition, peripheral 
galvanization or faradization should be tried ; the electric moxa, or gal- 
vanization of the brain or cervical sympathetic, has in some cases proved 
effective. 

Professor S. Leduc, of Nantes, 1 reported several cases in which he 
had obtained excellent results in neuralgia by the electrolytic intro- 
duction of salicylic ions (galvanic Cataphoresis). Eecently he has again 
resorted to this method with success in a case of tic douloureux of thirty- 
five years' standing. This patient was cured, according to Dr. Leduc, 
in three seances by salicylic ionization. The method followed was to 
apply the cathode, moistened with a solution of sodium salicylate, 
to the right side of the face, and at the first treatment the current 
was raised gradually to an intensity of 45 milliamperes and maintained 
there for forty minutes. After the second stance, which took place 
three days later (when the current was allowed to pass for one hour, 
with a current of 35 milliamperes), he experienced decided ameliora- 

1 La Semaine Me"dicale, November 22, 1905. 



98 ELECTEO-THERAPEUTICS. 

tioii. Finally, a third and last iouization, of forty minutes, brought 
about a final cessation of the pain. The pain now only returns during 
exposure to cold. 

Peripheral Neuralgia. Whatever the cause, these cases should be 
treated by stabile faradization and galvanization, or the electric moxa. 
In rebellious cases, central and general electrization should be tried. 

Sciatica. Faradization is to be recommended in this condition. For 
the novice, galvanization is to be preferred, owing to the extreme 
evenness of the current required. An ill-directed, prolonged current 
often aggravates the condition. I have had good results with the static 
spark. 

PARALYSIS. 

Rheumatic Paralysis. In these cases faradization is extremely useful. 
The electro- muscular contractility in recent cases is normal, in long- 
standing cases diminished. It is important to institute treatment before 
the occurrence of muscular atrophy. Static and galvanic electricity are 
also valuable in rheumatic paralysis. 

Syphilitic paralysis is treated in a manner similar to rheumatic pa- 
ralysis. 

Lead Paralysis. In this affection the electro- muscular sensibility is 
diminished and frequently lost, and diplegic contractions may appear. If 
the electro-muscular contractility is completely lost, apply a galvanic cur- 
rent, 5 to 15 ma., to the paralyzed part before the faradic current is 
employed. The latter current should be used daily, 10 to 15 minutes at 
each sitting. When the slightest contractions occur from the faradic 
current, the galvanic may be discontinued. 

Paralysis from opium, stramonium, arsenic, etc., is to be treated by 
general faradization. 

Hemiplegia. Treatment should not be commenced until four or five 
weeks after the attack. Vigorous electrization of the affected limbs may 
completely restore them. Further efforts may be directed to the cranial 
lesion by the application of the continuous current. The anode is applied 
to the forehead and to the sides of the head, the cathode to the nape of 
the neck ; the former electrode being moved slowly to and fro without 
interruptions. Current strength 1 to 5 ma. The active electrode should 
be of medium size. Daily treatments for one month ; duration of each 
sitting, 5 minutes. If aphasia be associated, the anode may be applied 
to the third left frontal convolution. I prefer the static breeze over the 
head, with indirect sparks to the affected side. 

Paraplegia. Early in the disease the galvanic and the faradic reac- 
tions may be normal. Where the posterior columns are affected, electro- 
anaesthesia may likewise coexist. Treatment consists in galvanization or 



APPLICATIONS IN DISEASED CONDITIONS. 99 

faradization. The electro- muscular contractility is frequently so much 
diminished that it becomes necessary to give particular attention to the 
motor points in order to produce contractions. 

Facial Paralysis. Facial paralysis should be treated by local faradi- 
zation and galvanization. When response is not obtained by the faradic 
current, it is of little use to employ it ; it being far better to depend 
upon the galvanic current. In this disease the current- re verser electrode 
is exceedingly convenient. A current just sufficient to produce contrac- 
tion is better than a stronger current, and short applications are 
preferable to long ones. 

Poliomyelitis. In poliomyelitis, the paralysis precedes the wasting. 
The faradic irritability soon becomes lost, with temporary increase of 
galvanic irritability and degenerative reactions. The latter are often 
mixed, due to the nerve-fibres being unequally affected, an increase of gal- 
vanic irritability in the muscles with retention of faradic irritability in 
the nerve. In infantile palsy, there is loss or absence of electro -muscular 
contractility. Treatment consists in the galvanization and faradization 
of the affected muscles, and the constitutional methods of treatment of 
general faradization, central galvanization, and static electrification. 

Locomotor Ataxia. The electro- muscular contractility may be normal 
or increased, as distinguished from ordinary motor paralysis, depending 
upon anterior or lateral spinal sclerosis. It may, however, be dimin- 
ished. The disease may be treated by galvanization of the spine, central 
galvanization, and general faradization, when cet-ebral disturbances or 
general ataxia of the nervous system appear, galvanization of the cer- 
vical sympathetic and peripheral faradization with sponges and the 
metallic brush. Static electricity by means of long percussive sparks 
over the spine is often useful. 

CHRONIC SPINAL MUSCULAR ATROPHY. 

The use of central galvanization is here indicated, with faradization 
and galvanization of the affected muscles. Static electricity is strongly 
commended by many electro-therapeutists. 

EPILEPSY; 

Erb recommends the following method : u Place the anode over the 
forehead, and the cathode to the neck. Current 1 to 2^ milliamperes. 
The duration of each treatment is about one minute. The position of 
the electrode is then changed ; the anode is then placed to the middle line 
of the head and the cathode to the occiput." 

I advise the administration of the static current ; especially the wave 
current or breeze over the head, has in some cases done good. The cur- 
rent should be applied every day, if possible, and continued for months. 



100 ELECTEO-THEKAPEUTICS. 

INSOMNIA. 

This affection frequently yields to treatment by electricity. I have 
seen patients fall into sleep while I was treating them with the static 
breeze. The galvanic current applied to the sympathetic system, or the 
faradic current applied to the head and spine, and also general faradiza- 
tion have given most encouraging results. The majority of electro- 
therapeutists incline to the opinion that the most favorable results are 
attained by employing the static current. 

HYSTERIA. 

In this condition a psychical effect is produced by the static 
and also by the galvanic current. It is also possible in many cases that 
a lessening of nervous irritability results from the electrical applica- 
tions. In fact very little, if any, good is done in this disease by the use 
of electricity. 

HYPOCHONDRIASIS AND MELANCHOLIA. 

In these conditions both general galvanization and faradization of 
the cervical sympathetic do good by the psychical effect upon the patient. 
Static electricity in some cases would appear to be beneficial. 

INSANITY. 

The various forms of insanity are at times favorably influenced 
by using the same treatments as are referred to in the preceding para- 
graph. It is unfortunate that in asylums electricity has not been more 
extensively employed. The use of the static bath would seem to be 
beneficial, and to this end experiments are being conducted at the Phila- 
delphia Hospital. 

NEURASTHENIA. 

Dr. Charles K. Mills * believes that electricity used only in the form 
of general faradization, with a slowly interrupted current, is less useful 
than massage. In not a few cases, the nurse who attempts to give faradic 
electricity to a patient is unskilful or irritating in her method of admin- 
istration. On the whole, Mills prefers the method of direct muscular 
faradization, supplemented with gliding or labile currents, applied to the 
entire limb or part. The nurse holds two moistened electrodes in one 
hand, and passes from one muscle to another ; then placing one elec- 
trode to the spine or in the neighborhood of the nerve plexus, the 
electrode is passed from point to point down the limb. 

transactions of the Philadelphia County Medical Society, Nov. 29, 1905. 



APPLICATIONS IN DISEASED CONDITIONS. 101 

Dr. W. B. Snow 1 says in reference to the electrical treatment of 
neurasthenia : "For the general tonic effects indicated in every case of 
neurasthenia, the wave current should be administered, by placing the 
long, spinal electrode (one inch in width and 18 to 22 inches in 
length) over the vertebral column from the cervical to the lumbar re- 
gion for from at least 15 to 20 minutes, and employing as long a spark- 
gap as may be used without causing uncomfortable muscular contractions. 

' ' Patients will usually take a treatment with a four-inch spark. 
Though persons with small muscles and but little fat may not bear a two- 
inch spark-gap current, large or fat persons will bear and require one 
measured by a five- or six-inch spark discharge. After the first few 
applications, the patient perspires gently with each such treatment. 
Not only does the activity of sweat glands resume, but there is a grad- 
ually increasing resumption of other functions. There is marked in- 
crease in the daily excretion of solids in the urine, digestion improves, 
appetite returns, the bowels become more regular. 

u While many cases have been cured by no other agency than the 
wave current, we believe that the active peripheral stimulation and mas- 
sage afforded by the long and friction sparks hasten the recovery of every 
case, the time factor of which will depend on the duration of the affec- 
tion, the adherence to regimen, the extent of functional derangement, 
the recuperative powers of the patient, the regularity with which the 
treatments are administered, and the technic employed. Treatment 
should be given daily for at least two weeks, when every second day may 
suffice. ' ' 

EXOPHTHALMIC GOITRE. 

In the treatment of exophthalmic goitre, Dr. Francis B. Bishop, 2 of 
Washington, believes that the only rational method of procedure is by 
means of the electric current. 

The vagus is easily stimulated in the neck from the subauricular 
fossa to the clavicle, and with a much weaker stimulus and in much less 
time than the sympathetic. So with care we may get the inhibitory and 
other influences of the vagus, without unduly exciting the sympathetic. 

Preference for the application to the vagus, has been for the 
continuous current, and the method of application has been to stimulate 
both nerves at the same time. A large sponge-electrode, attached to the 
positive pole, is placed high up on the back of the neck. A bifurcated 
cord is used for the negative side, and two small sponge-electrodes are 
placed one on each side over the pneumogastric, in the lower part of the 
neck and impinging upon the thyroid. 

1 Post-Graduate, December, 1900. 

2 The Journal of Advanced Therapeutics, February, 1904. 



102 ELECTRO-THEKAPEUTICS. 

"The current is gradually turned on and the pulse noted," says 
Bishop ; "the current is allowed to remain at that point for ten or fifteen 
minutes, or longer, until a decidedly quieting effect has been produced. 
Then the small sponges are placed directly on the gland and the current 
turned on to the point of tolerance, and is allowed to pass from five to 
eight minutes. This treatment is persisted in every other day, and in 
many cases a decided improvement will be noticed in a month. Later, 
I have been using the high-potential, high-frequency current as an 
auxiliary, and have been much pleased. One patient begged me to dis- 
continue all other treatment, as she was so much benefited by the high- 
frequency spark applied directly to the thyroid and cervical spine, over 
the liver, spleen, kidneys, abdomen, and over the region of the ovaries. 
A letter received some time ago states that she continues to improve." 

Heiiman's 1 experiences with electro- chemical treatment of exophthal- 
mic goitre encourage further work in this line, he thinks. He applies 
the cathode over the goitre with the continuous current, 25 to 40 milliam- 
peres, similar to Bordier's technic, except that he uses a % cathode which 
contains potassium iodide. In one case, for instance, he applied a cur- 
rent of 20 inilliamperes for about twenty minutes a day, the positive 
electrode oii the back, and the negative on the neck. The cathode was 
placed on a thin sheet of lead, shaped to the neck, over sevoi'al layers of 
sterile gauze impregnated with a concentrated solution of potassium 
iodide, covering the entire goitre. The current was turned on and oif 
very gradually. After a week of this treatment all the symptoms of the 
exophthalmic goitre had disappeared, and the size of the neck had been 
reduced from 39.5 cm. to 38 cm. The patient felt perfectly well and has 
continued in good health since that time November, 1905. The im- 
provement in another case described was almost equally striking, and in 
this case iodide was found in the urine five days after the last appli- 
cation. He also detected iodine in gauze under the anode of the back. 
Other cases from his experience are described and some of the laws of 
electro-chemistry are cited to explain the phenomena observed. 

VII. Gynecology. 

The value of electro -therapeutic measures in gynecology has been 
for many years a subject of heated discussion among its many champions, 
and among the equally numerous opponents to its employment in diseases 
peculiar to women. 

Dr. Barton Cook Hirst, 2 of Philadelphia, remarks that of late he 
has found galvanism and faradism of value in a limited numlxM- of 

1 Hygieia, Stockholm, Last Index, p. 903. 

5 " Limitations and Possibilities in the Treatment of Diseases of Women," read 
before the Philadelphia County Medical Society, January 25, 1J)05. 



APPLICATIONS IN DISEASED CONDITIONS. 103 

conditions in gynecological practice. As a haemostatic in uncomplicated 
small fibroid tumors, with no other symptom than metrorrhagia, he 
regarded it as a most efficient agent. He found it peculiarly useful in 
the treatment of amenorrhcea and sterility, the results of imperfect 
development or atrophy of the uterus. Two illustrative cases were 
reported in which normal menstruation was restored and conception 
occurred after the use of this treatment. In one woman there had been 
amenorrhoea for a year. In the other, the menstruation had been reduced 
to a scanty discharge lasting less than a day, as a result of lactation 
atrophy. The third indication was to restore tone to a paretic sphincter 
ani muscle, after its imperfect restoration by surgical means, in which 
there had been no contractile power exercised for a number of years. A 




Fia. 50. Vesical electrode, for hydro-electric application to female bladder. Useful in atony, dila- 
tation, chronic cystitis, etc. 




FIG. 51. Goelet's iutra-uteriiie electrode, with interchangeable tips. 

fourth indication was found in certain types of dysmenorrhoea associated 
with an ill-developed uterus. Local treatment, however, he believed, 
was very rarely practicable in such cases. 

In disease of the uterus, local, central, and general treatment may be 
employed. Local treatment may be external or internal. 

The uterus and the appendages may be treated electrically by 
applying one pole over the hypogastrium and the other over the lumbar 
region. In virgins this method should always be tried first. 

In the internal method, one pole may be applied to the os by means 
of an insulated electrode with a metallic belt, while the other, bearing a 
broad electrode, is applied to the back, or on the hypogastric region, or 
over an ovary. 

In using the faradic current, both poles are applied internally. The 
sinusoidal current is of great value for the alleviation of uterine pain. 
Figs. 50 and 51 illustrate two valuable electrodes in gynecological work. 



104 ELECTRO-THERAPEUTICS. 

AMENORRHCEA. 

For ainenorrhoea Dr. Golding Bird l believes in the value of shocks 
from the Leydeu jar. He transmits twelve successive shocks, from the 
sacrum to the pubes. Panecki uses the induction coil. In chlorosis, 
marked benefit is said to accrue from the nutritional effects of the electric 
bath. In healthy women who menstruate regularly, electricity often 
hastens the flow, especially when applied to the abdomen or pelvic re- 
gion. Another method consists in having the patient lie on a large elec- 
trode, and in applying a circular one with the handle alternately to the 
epigastrium and hypogastrium, stabile, using 30 milliamperes. This 
should be succeeded by a strong primary faradic current. 

D YSMENORRHCEA . 

When this affection is due to a cervical stenosis, electrolysis is indi- 
cated. For dysmenorrhosa, independent of stenosis or structural change, 
the galvanic current is of value in relieving congestion and pain. The 
applications are to be made prior to menstruation and repeated daily. 
These same applications offer most beneficial results in dysmenorrhoea 
dependent upon pelvic cellulitis ; occasionally the faradic current is of 
value. 

FIBROID TUMORS. 

The electrical treatment of uterine fibromata has been elaborately 
studied by Bartholow, Massey, Eugelmann, and many others. Indeed 
since the brilliant investigations by Apostoli, the literature of uterine 
fibromata has assumed massive proportions. In 1882 Apostoli, in an arti- 
cle to the Academic de Medecine, expounded his views on a subject here- 
tofore unthought of, that at once aroused attention and invited thought. 
He advised the use of an internal platinum positive electrode, and an 
abdominal negative electrode, of large surface, made of moist china clay, 
with a continuous current of 60 to 70 milliamperes. Applications 5 to 
15 minutes. Stances once or twice weekly. The current was to destroy 
the mucous membrane, which was succeeded by a healthy repair process 
and by a cicatrization to check the metrorrhagia. 

Bergonie and Boursier 2 sum up the results they obtained in one hun- 
dred cases of uterine fibroids as follows : ' * The electric treatment of 
fibro-myomata is undoubtedly efficacious as a palliative method of treat- 
ment. When hemorrhage was the chief symptom complained of, 90 per 
cent, were relieved. The general state of health was improved in 79 per 
cent.; the pain was relieved in 50 per cent., while a decrease in the size 
of the tumor was observed in 10 per cent, only." 

'Electricity and Magnetism, 1849, Lecture V, and Appendix B. 
Arch. d'Electricite m&iicale, 1893, 211. 



APPLICATIONS IN DISEASED CONDITIONS. 105 

OVARIAN TUMORS. 

The electrolytic treatment of these tumors, which was formerly so 
largely in vogue, has beeu completely abandoned by electro-therapeutists. 
The danger incident upon operation is less than that incurred by 
electrolytic means. 

CHRONIC METRITIS. 

In these cases either the faradic or galvanic current may be used. 
The more usual method is to apply the galvanic current. Place the 
anode (per speculum) upon the os, and the cathode upon the epigastrium, 
stabile 5 to 10 minutes, 2 or 3 times a week. Current about 20 milli- 
amperes. 

PERIUTERINE H.EMATOCELE. 

Apostoli's method is intended to effect a chemical caustic change by 
means of the cathode. A fistula is thus established, which tends to 
remain open, with adhesions between the seat of the affection and the 
external mucous membrane. 

STENOSIS OF THE CERVICAL CANAL. 

In these cases galvanism is of great value. Introduce a sound, con- 
nect it with the cathode, apply the anode to the abdomen. Current 50 to 
75 milliamperes j application 5 minutes. 

SUBINVOLUTION AND ATROPHY. 

Early in the condition, the faradic current is most useful, applied by 
means of the bipolar electrode. Later in the affection the galvanic cur- 
rent is to be employed, and the treatment to be instituted is similar to 
that for chronic metritis. 

URETHRAL CARUNCLE. 

If pedunculated the galvano-cautery snare is passed around the 
caruncle and the current turned on. The carbon or platinum electrode 
is used, covered with absorbent cotton saturated in a solution of cocaine. 
Current 5 to 15 milliamperes. When no pedicle exists, puncture with a 
negative needle ; current 10 to 15 milliamperes. 

POST-PARTUM HEMORRHAGE. 

Use current of the primary wire with an inter-uterine electrode, with 
the indifferent electrode on the abdomen. A pocket faradic battery 
answers admirably, that of Gaiffe of Paris being deservedly popular. 



106 ELECTRO-THERAPEUTICS. 

VOMITING OF PREGNANCY. 

In vomiting of pregnancy the induction coil of fine wire is preferably 
employed. Apply the anode to the nape of the neck, the cathode to the 
epigastrium. Avoid the uterine region. 

SLOW LABOK. 

This may be hastened, and atony and inertia of the uterus overcome 
by the use of the faradic current. Electrodes of large size are applied 
on each side of the fundus, near the umbilicus. A powerful current is 
passed with the occurrence of a pain. 

Dr. C. A. Covell, in a paper entitled "A Case of Asthma with Fi- 
broids and Pelvic Adhesions Cured by Galvanism," ' mentions the case of 
a patient, aged 37, married, who suffered with marked dysmenorrhoea and 
bearing-down pains. The pelvic trouble became constant, and she was 
advised to undergo an operation for hysterectomy and ovariotomy. The 
author then says, "because of the great tenderness and pain I used the 
vaginal abdominal alternations, a large pad of absorbent cotton and wire 
being placed over the abdomen and a Leclanch4 zinc insulated with rub- 
ber tubing, the tip covered by cotton, was placed in the vagina. Gradu- 
ally turning the current on and off, and reversing it occasionally, from 25 
to 100 milliamperes were used, she being able to bear more current some 
days than at others. Treatments were given at first every other day and 
later twice a week only. Improvement was rapid. In six mouths the 
exudate was absorbed, and in one year the pelvic organs were nearly 
normal. The fibroids were reduced to the size of a walnut. The pain 
ceased, and as the pelvis cleared the asthma became less and less, finally 
ceasing also. 

"I did not see her again professionally for four yeai-s. One 
year since she became pregnant, without any unusual symptoms. She 
went to full term, and in May last was delivered at the Good Shep- 
herd Hospital of a nine-pound boy. Labor lasted five hours and was 
normal in all respects. While she was under chloroform I carefully 
examined the uterus and found two interstitial fibroids the size of my 
thumb. 

" To me the interesting things about this case are these : The asthma 
was of reflex origin and ceased as the pelvic condition was relieved. 

"The method of application of the current in periuterine inflam- 
mation. 

"The uterus, which the leading gynecologist of central New York 
said it was necessary to remove to save the patient's life, under elec- 
trical treatment produced four years later a healthy child." 

1 Read at the Thirteenth Annual Meeting of the American Electro-Therapeutic 
Association, Atlantic City, September 23, 1903. 



APPLICATIONS IN DISEASED CONDITIONS. 107 

VIII. Aneurism. 

Treatment of aneurism by electro- puncture dates back to Pravaz 
(1838), Peterkin (1845), and Ciniselli (1870). 

Ciniselli l has collected 23 cases of aneurism, six of which were appar- 
ently cured by electro -puncture, 10 died, and in one case result is not 
known. The operators sometimes used one needle in the sac, sometimes 
both. Tripier advocates the insertion of the positive needle only, on 
account of its property of coagulating albumen. In Ciniselli' s cases, 20 
to 40 cells were used from 10 to 30 minutes. The method now frequently 
employed is to take a fine coiled wire of gold, silver, or platinum, so drawn 
out that it may be readily passed through a thoroughly insulated needle. 
The anode is the active electrode, the cathode, a clay pad on the abdomen. 
The current may gradually ascend to 80 milliamperes. Duration 30 to 
60 minutes. 

Cornelius A. Griffith 2 describes an interesting case of sacculated 
aneurism of the abdominal aorta, treated by the introduction of silver 
wire and the passage of the constant current. 

The tumor was in the epigastric region, lying almost directly to the 
left of the middle line, extending up under the ribs and downward nearly 
to the umbilicus, its size being about that of a cocoanut ; it caused some 
bulging of the epigastrium, was distinctly pulsating, and presented a 
well-marked systolic bruit. Pain was constantly present in the back 
and at the left side, and also in the epigastrium, following the taking 
of food ; occasional retching was experienced, but there was no actual 
vomiting. 

Subsequently an operation was determined upon, when a fine, long, 
metal trocar and canula were thrust well into the sac, the trocar was 
withdrawn, and a vulcanite insulating canula substituted, through which 
fine silver wire was introduced into the sac. About six feet of wire were 
passed in, connected to the negative pole of a constant current battery, 
and 15 to 25 milliamperes passed for 15 minutes. At the end of this 
time it was noticed that the tumor was harder and the pulsations 
had grown less. The canula was then withdrawn and the operation 
completed, whereupon it was noticed that the bulging caused by the 
tumor had almost disappeared. Patient died in about five hours, 
apparently from shock. Port-inortem examination showed that the 
sac was filled with a dark clot about the coiled wire, and that a double 
loop of the wire had been passed for about two inches up into the 
thoracic aorta. The introduction of coils of wire in aneurismal sacs 

1 Luigi Ciniselli ("Sugli aneurismi dell' aorta toracica finora trattati colla elletro- 
puntura ") , Milliano, 1870, quoted in Dr. Keyes's paper on " Practical Electro-Therapeu- 
tics," New York Med. Journal, Dec. 1871. 

2 London Lancet, August 12, 1905. 



108 ELECTRO-THERAPEUTICS. 

should be avoided if possible, and the immediate clotting of the blood 
within the sac by the passage of a small current is believed to be of 
advantage. 

Dr. H. A. Hare l reported eight operations of this nature, the three 
now reported, making a total of eleven, in his own experience. 

The first of these three cases occurred in a woman of 50, the aneu- 
rism involving the superior and posterior portions of the transverse arch 
of the aorta, and included the origin of the large vessels arising from this 
part of the aorta. The occurrence of severe symptoms made relief 
imperative, and gold wire to the amount of eight feet was passed into the 
sac through an ordinary insulated needle, and through this wire was 
passed an electrical current started at 5 milliamperes and gradually 
increased to 50 milliamperes for 30 minutes. The immediate effect of 
the operation was to relieve the pressure symptoms, and for several 
weeks afterward she was able to sleep in a reclining posture with perfect 
comfort. Six mouths later the growth began to enlarge at the margin of 
the clot, and death finally occurred from pressure and exhaustion. 
Autopsy confirmed the diagnosis in every particular, and revealed the 
wire embedded in the clot. 

The second case occurred in a man aged 42, and was probably trace- 
able to heavy lifting. There was some paralysis of the right vocal cord, 
but no interference with swallowing ; the growth filled the epiclavicular 
space at the right side, and passed backward under the sterno-mastoid 
muscle, pushing apart the bellies of the two branches of this muscle 
and protruding prominently into this space. Two feet of gold wire were 
passed into the tumor and the current passed as before, from 5 to 50 
milliamperes being used in the course of 40 minutes. The patient was 
relieved immediately after the operation, and his voice, to some extent, 
soon returned. Four months later, however, he died from exhaustion and 
pressure. Autopsy confirmed the diagnosis, but, strangely enough, no 
trace of the wire could be found in any part of the clot. 

The third case occurred in a woman aged 50, and involved the 
thoracic aorta just below its descending portion. Erosion of the ribs 
was noted upon the left side, so that the sac projected to the extent of 
two inches outside of the line of the body between the vertebra3 and the 
lower third of the left scapula. Nine feet of wire were introduced and 
the current passed as in the preceding case, from 5 to 50 ma. during a 
period of three-quarters of an hour. The immediate effect of the opera- 
tion was to diminish the expansile pulsation. At the end of four months, 
however, the patient died from pressure symptoms and exhaustion. The 
autopsy confirmed the diagnosis and revealed the wire embedded in the 
centre of the clot. 

1 Therapeutic Gazette, July 25, 1905. 




FJG. 52. Ozone inhalation. The generator should be suspended to within a few inches from 
the mouth of the patient, and attached to the positive pole of the machine. The patient is placed 
upon an insulated platform connected with the negative pole. The oxygen of the air confined within 
the globe is broken up, forming ozone, by the convective discharge of the current passing from the 
numerous points of the brush within. It is of paramount value where sprays or medicated vapors 
cannot reach the part by other means. 



CHAPTER IX 
APPLICATIONS IN THE SPECIALTIES. 

I. Rhinology and Laryngology. 
ATROPHIC KHINITIS. 

IN atrophic rhinitis, Delavan 1 suggests the application of the nega- 
tive pole to the retro-nasal space, and the positive pole to the nape of the 
neck. The strength of the galvanic or faradic current should be from 4 
to 6 milliamperes. Each treatment should last from 5 to 12 minutes. The 
applications should be made every other day. 

PHARYNGITIS. 

Hahn 2 asserts that he obtained good results in cases of pharyngitis 
by the use of the faradic current. Violet rays and high-frequency cur- 
rents have frequently proved useful. In pharyngitis, and in many 
pharyngeal and laryngeal affections, ozone inhalations have been warmly 
commended (Fig. 52). Many ingenious electrodes for nasal and pharyn- 
geal work have been devised, two very useful ones being shown in Figs. 
53 and 54. 




FIG. 53. Curved sponge electrode for application to throat. 




FIG. 54. Electrode for hydro-electric applications, postrnasal and pharyngeal. 



In this affection some electro-therapeutists apply cupric electrolysis. 
In 1895 at a meeting of the Belgian laryngologists and otologists, Cheval 

1 Transactions of the American Laryngological Association, 1887, p. 146. 
* Journal de Meclecine, Paris, November, 1902. 

109 



110 ELECTRO-THERAPEUTICS. 

announced the cure of 91 per cent, of cases of ozieua at a single stance. 
He employs a copper needle (positive pole) and inserts it into the mucous 
membrane of the middle turbinated bone, and introduces a steel needle 
into the mucous membrane of the inferior turbinated bone of the same 
side. The strength of current is between 18 and 20 inilliaruperes, for a 
period of 10 minutes. 

ANAESTHESIA OF THE PHARYNX. 

Induced or continuous currents, percutaneous or pharyugeal, may be 
used in such cases. Short static sparks are often beneficial. 

LARYNGEAL FATIGUE (fatigue vocale). 

Bordier ' states that Moutier and Granier of the Opera in Paris, 
had been able to prove that electro-static applications exerted a 
favorable influence upon laryngeal fatigue. The patient was charged 
negatively and the anode or grounded point electrode was applied 
near the mouth and nose. Applications daily for 15 or 20 minutes 
showed an increased duration of the respiratory movements, the pitch of 
the laryngeal sound was raised, and the quality of the voice became 
more agreeable. 

ATROPHIC PHARYNGITIS. 

Shurley 2 used cocaine in the treatment of atrophic pharyngitis and 
then applied one electrode through the nose, and the other to the pos- 
terior and lateral wall of the pharynx. The current increased both the 
color and secretion of the membrane. With the use of the faradic 
current, Sajous has obtained good results. 

ANOSMIA. 

Anosmia may result from long continued rhinitis or from a 
peripheral lesion. 

The treatment may be external and internal. The external treat- 
ment is the same as for rhinitis, save that the current is stronger. The 
internal treatment consists in the direct application of a metallic electrode 
to the nasal mucous membrane. 

Rockwell mentions a case of anosmia $ of six years' duration, where 
the patient could only perceive the odor of kerosene oil and freshly 
ground coffee, and who was entirely cured by two applications of the 
faradic current 

1 " Medical Electricity," by H. Lewis Jones. 

1 Transactions of the American Laryngological Association, 1887, p. 146. 

s Medical and Surgical Electricity, by A. D. Rockwell, p. 482. 



APPLICATIONS IN THE SPECIALTIES. Ill 



ASTHMA. 



The galvanic current over the pneumogastric and sympathetic 
regions has been frequently used in asthma, with asserted good results. 
The faradic current is sometimes effective. In some instances persistent 
faradization of the chest and neck has been followed by marked relief. 

Courtade, in a communication made to the Societe Medico-Chirur- 
gicale, 1 recommended the application of electricity to the lateral cervical 
region. The positive pole is placed on the neck, so as to produce a con- 
dition of electrotonus, i. e., a diminution of the excitability of the nerve. 
Thus directed the current acts upon the pneumogastric at first in a cen- 
trifugal manner, so as to excite the bronchial and laryngeal muscles; 
following this it acts centripetally upon the phrenic nerve, and upon 
the great sympathetic. The excitation of the latter is able to modify 
the vaso-motor activity of the vessels of the medulla oblongata and the 
respiratory centres. The results were found to be very favorable in 
essential asthma. 

II. Otology. 
AUDITORY-NERVE DEAFNESS. 

This is best treated by the bifurcated electrode and the battery cur- 
rent, using the cathode to the ears. Gradually vary the current by 
employing a rhythmic interrupter, or by turning the current on and off 
with the current collector. Ten milliamperes is the maximum. Seances 
of 5 or 6 minutes are long enough. Apply to both ears simultaneously, 
so as to prevent vertigo. Use electrodes of a one-inch surface. Place a 
small pad of moist absorbent wool between the electrode and the skin, 
because, the electrode being small, the density of the current is great. 
One variety of the double ear electrode is shown in Fig. 55. 




FIG. 55. Double sponge-tipped ear electrode insulated with hard rubber. 

CHRONIC SUPPURATION OF THE MIDDLE EAR. 

Eockwell states that in experimenting on these cases he used the gal- 
vanic current. The theory on which the experiments were based was 
that ulcerous conditions in the ear might be treated electrically, similarly 
to the same conditions elsewhere. An electrode with a long, narrow 
extremity, covered with a little cotton, was inserted into the auditory 

1 Le Bulletin Mddicale, February 21, 1906. 



112 ELECTRO-THERAPEUTICS. 

canal through a rubber speculum, the canal being filled with tepid 
water. The electrode is usually connected with the negative pole of the 
galvanic current, though sometimes with the positive. The circuit is 
completed by the hand of the patient holding a sponge electrode, or rest- 
ing on a stationary electrode. Weak currents and short applications are 
to be employed, while some form of rheostat is indispensable. 

TINNITUS AURIUM. 

Subjective noises can sometimes be dispelled at once by battery 
currents. 

In chronic ear disease, when patients are electrically treated, the 
tinnitus is often found associated with great increase in the irritability of 
the auditory nerve. 

In treating tinnitus aurium select two small, well-padded electrodes, 
of about 2 cm. in diameter, to form a divided anode ; apply one to each 
ear, just in front of the tragus. The cathode (an electrode of large size) 
is applied to the nape of the neck. The current is slowly raised to 5 
milliamperes. Duration 10 minutes. The anode usually diminishes the 
tinnitus, the cathode inrceases it ; sometimes the reverse occurs. If no 
improvement follow either application, it is futile to continue. 

Dr. William S. Bryant l details excellent results obtained from elec- 
trical treatment in tubal tinnitus wherein other methods had failed. The 
negative pole can be applied to the tube, preferably through the nose. 
It is best made in the form of an eustachian catheter, conical at the tip, 
and in three sizes. It should be insulated to within three-quarters of an 
inch of the end of the electrode. Duell's electric bougie is very satis- 
factory in the most refractory cases. Atrophy calls for stimulation and 
electricity. 

As a complete resumS of the uses of electricity in aural diseases and 
affections, I can do no better than append the following abstract from the 
excellent paper of Dr. J. J. Richardson, of Washington, D. C., entitled 
"Electricity in Otology." 2 

u * * # * i am no t an enthusiast, who claims electricity to be a 
panacea for all diseases, but after careful experimentation and observa- 
tion, I am convinced that it at least possesses great possibilities along cer- 
tain lines. * * * * I know from practical experience that we can 
by its employment in one form or another (1) stimulate weak muscles, 
(2) relieve pain, either by direct action of the current or by the cata- 
phoric application of anaesthetics, (3) stimulate absorption of inflam- 
matory exudates, (4) overcome stenosis or complete strictures, and (5) at 
times revive nervous activity. A thorough knowledge of the physiology 

laryngoscope, July, 1904. 

J New York Medical Journal, February 25, 1905. 



APPLICATIONS IN THE SPECIALTIES. 113 

and pathology of the parts we are treating and also of electro- physiology 
and electro-physics is demanded. The apparatus must be of the high- 
est standard and under perfect control, as otherwise we are assum- 
ing a risk which is unjustifiable, and may inflict injury instead of 
affording relief. For example, in the application of galvanism, the 
polarity of the current is of the greatest importance. The negative pole 
will often do good whilst the application of the positive may be painful 
and even injurious. * * * * Again, a mild current will fre- 
quently relieve or cure conditions where a stronger one would aggravate 
them. 

u * * * * There are different methods of applying electricity to 
the ears. The one which I employ for both the galvanic and faradic cur- 
rents, when both ears are to be acted upon, is a bifurcated intra-auricular 
electrode, the metallic ends of which I cover with moist absorbent cotton. 
For the indifferent pole, an ordinary sponge electrode is placed in the 
hand or over the nape of the neck. I frequently apply it to the 
eustachian tube by introducing a hard-rubber catheter in the ordinary 
way, and passing through it a metallic bougie electrode, applying the 
other electrode over the mastoid region. In this way it acts directly on 
the muscles of the tube, which at times lose their normal tonicity, and it 
also stimulates the circulation of the parts. For this purpose I usually 
employ the faradic current, which produces a sort of tingling sensation, 
but no vertigo or other symptoms of cerebral irritation. 

"The active pole for therapeutic purposes should most always be 
the positive, unless electric torpor exists, as it is the sedative, deconges- 
tive one. The negative pole, which we employ in studying the auditory 
nerve excitability, acts in the inverse sense ; with the faradic current the 
polarity is unimportant. 

1 i In the distressing symptom of tinnitus, electricity will frequently be 
beneficial where other forms of treatment have been of no avail. It is 
in these cases where the ordinary treatment of inflation, eustachian and 
middle ear medication have been instituted, and where the naso- pharynx 
and nasal cavities have been treated with negative results, that electricity 
offers some encouragement. A fair percentage of the patients will be 
greatly .benefited, and one occasionally cured. When the tinnitus is of 
labyrinthine origin, or due to chronic inflammatory changes in the middle 
ear, the constant current is the one mostly employed. One to three 
milliamperes are sufficient and should be allowed to pass from 6 to 10 
minutes. Where there is ankylosis of the ossicles, the interrupted 
current has been more satisfactory in cases, although less frequently 
employed than the constant current. The good effects are to be found in 
its mechanical action on the adhesions, and to its stimulating action on 
the circulation, and also upon the weakened muscles of the middle ear. 



114 ELECTRO-THERAPEUTICS. 

" True strictures of the eustachiau tube are rare, and are best treated 
by electrolysis. The galvanic current is utilized for this purpose. A 
hard-rubber or silver catheter, properly insulated with rubber up to its 
point, is introduced, and a small gold bougie is passed through the cathe- 
ter and up to the point of constriction in the tube ; the bougie is the 
active electrode. It is to be attached to the negative pole of the battery, 
the current turned on slowly, and 3 to 6 milliamperes are to be allowed 
to pass. After 6 or 8 minutes, by a gentle pressure on the bougie, it will 
be felt to pass the softened stricture. The operation is a little painful, 
and for a few days following there will be an increased amount of deaf- 
ness and ringing and fulness in the ear. On the third day usually a 
celluloid bougie is to be passed and at the same intervals of 3 or 4 days 
for 2 or 3 weeks. The dispensing electrode is held in the hand in pref- 
erence to the mastoid region, or over the neck, where there will be less 
tendency to cerebral irritation. 

" Complete success, by electrical treatment, for deafness either of 
tympanic or labyrinthine origin, is of rare occurrence. I do not recall 
any cases that I have treated where the hearing was greatly improved, 
except those naturally resulting from the diminution of the subjective 
noises. Hysterical deafness, like hysterical aphonia, is best treated by 
the faradic current. Pruritus of the auricular canal is often benefited 
by this form of treatment. In neuralgic otalgia the interrupted current 
is very efficacious when applied by means of an intra-auricular electrode. 
The incomplete anaesthetic effect of cocaine may be aided by the action 
of the constant current. This cataphoric process is utilized in producing 
anaesthesia of the tympanic membrane and external canal for slight oper- 
ative procedures. The auricular canal is filled with a 10 per cent, solu- 
tion of cocaine and a mild current allowed to pass for 5 to 10 minutes, 
when anaesthesia ensues. This same process has been utilized by some 
with various drugs as a means of curing deafness, but I have had no 
personal experience along these lines, and the results published are not 
encouraging. The positive pole should be in contact with the fluid, and 
the negative pole applied over the neck." 

III. Ophthalmology. 

PARALYSIS OF THE MUSCLES OF THE EYE. 

This may be cerebral or peripheral in character. For this paralysis, 
galvanic currents are preferable. When the condition is thought to be 
cerebral in origin, galvanization of the sympathetic should be resorted 
to. Treatments of a half-minute duration are to be employed. 

BLEPHAKOSPASM. 

Galvanization or faradization is here indicated, for the same reason that 
it is indicated in torticollis. Ptosis is to be treated in a similar manner. 



APPLICATIONS IN THE SPECIALTIES. 115 



CATARACT. 



The Russian observer Crussel 1 claimed to have obtained perfect suc- 
cess in cases of cataract by the galvanic current. His method was to 
introduce a needle into the lens, which was connected with the negative 
pole, while the positive was applied to the tongue; in this way, the cata- 
ract was subjected to mechanical disintegration by the needle, to the 
chemical influence of the negative pole, and probably also to the macer- 
ating action of the aqueous humor penetrating the lens, through the 
puncture made in the capsule by the needle. 

ELECTROLYSIS IN DISEASES OF THE LACRYMAL CANAL. 

Lotine 2 reports a number of cases of disease of the lacrymal pas- 
sages in which he successfully employed electrolysis applied by electro- 
lytic probes, which were insulated along the greater part of their length 
by a coating of the same material as that used to cover elastic bougies. 
The particular portion of the probes so insulated could thus remain in 
the canaliculus and the lacrymal sac, while the non-insulated part could 
occupy the lacrymal duct. The technic was as follows : After dilating 
the canals and finding the stricture, the insulated probe, connected with 
the negative pole, is introduced into the strictured portion of the lacry- 
mal duct. Then the positive pole, wrapped in cotton, moistened in salt 
solution, is held in the patient's hand or introduced into the correspond- 
ing cavity of the nose. The resistance is gradually decreased for half a 
minute until the current measures from four to five milliamperes. The 
probe is then moved along the strictured portion, and the electrolysis is 
continued for about five minutes as a rule. The size of the probe used 
at first should correspond to that of the ordinary sound which just passes 
the stricture. Later the size of the electric probe may be increased. 

RETINAL ANAESTHESIA AND ITS TREATMENT BY VOLTAIC ALTERNATIVES. 

Dr. L.Webster Fox 3 defines retinal anaesthesia as a functional disorder 
characterized by reduction in acuity of vision and marked contraction 
of the visual fields (30 to 55 in both vertical and horizontal meridians), 
unaccompanied by reversal in the color fields. * * * * The treat- 
ment recommended is the daily application of a weak current of 1 or 2 
milliamperes, the session being of ten minutes' duration. The indifferent 
electrode is applied to the temple or nape of the neck ; the active elec- 
trode is applied over the eye or eyes. A convenient form of electrode for 
this purpose is shown in Fig. 56. Improvement follows within a few 

1 Evetzky " On the Nature of Cataract," New York Medical Journal, July, 1880. 

2 Roussky Vratch, May, 1904. 

3 Journal of the American Medical Association, January 7, 1905. 



116 ELECTEO-THEEAPEUTICS. 

days, and recovery is rapid. Errors of refraction should be noted, but not 
corrected until the cessation of electrical treatment. Voltaic alternatives 
are defined as a series of sudden reversals in the polarity of the electrodes 
of a voltaic battery, so as to produce an interrupted alternating current. 
The reversals used were at intervals of two seconds. Twenty-eight cases 




FIG. 56. Adjustable eye electrode, for one or both eyes. Adjustable to any pupillary distance. 

were treated with invariable benefit, the only return case being one of 
progressing myopia, which was fitted with glasses before completion of 
electrical course. The author asserts ' ' eminent success in numerous other 
lesions of the eye, vitreous opacities, retinitis pigmentosa, chorio-retiuitis, 
and choroiditis, treated by this method." 

MISCELLANEOUS OPHTHALMIC AFFECTIONS. 

Dr. W. Franklin Coleman 1 details an extensive experience with the 
use of electricity in ophthalmic practice, with the galvanic and sinusoidal 
currents. 

The cases selected were very chronic and regarded as incurable ; and 
in order that the results obtained could be ascribed to the current, the 
diagnosis had been confirmed by confreres and all other forms of treat- 
ment avoided. 

Prior to 1890, he employed the galvanic current of zinc-carbon ele- 
ments, excited by a solution of potassium bichromate ; since that time, 
however, he has used the Edison street current, controlled and measured 
by the rheostat and meter of the ordinary wall plate. 

The alternating or sinusoidal current was taken from a transformer, 
he using 30 to 35 measured volts, and a quantity measured at 5 milliam- 
peres. With a force of 30 volts taken from the direct current, and the 
electrodes placed on the lids and nape of the neck, the meter registered 5 
milliamperes, hence the same voltage from the alternating current and 
the same resistance. 

He prefers galvanism, in consecutive optic atrophy, because of the 
existing exudates ; while in primary atrophy, the alternate current would 

1 Transactions of the Section on Ophthalmology of the American Medical Asso- 
ciation, Boston, June 5-8, 1906. 



APPLICATIONS IX THE SPECIALTIES. 117 

appear more stimulating to the nerves. This can be shown by comparing 
a thirty- volt current from the dynamo with a thirty-volt galvanic cur- 
rent ; the former is not unpleasant and causes a brilliant mosaic of dark 
and light, while the latter causes no phosphenes, unless the current is 
interrupted and the burning is so intense that it cannot be endured for 
more than half a minute. 

He summarizes his cases as follows : 

Optic Atrophy. Fourteen patients, 23 eyes. In 5 eyes in which 
vision = light, 40 per cent, were improved, one to seeing hand move- 
ments and one to 20/67. 

In 18 eyes in which vision = form, 64 per cent, were improved. 
Four, 60 to 125 per cent. ; two, 300 per cent. ; three, 500 per cent. ; one, 
1500 per cent. ; two from seeing fingers to reading. In six there was no 
improvement. 

Vitreous Opacities. Seven patients, 12 eyes. In 5 eyes vision 
light, one improved to counting fingers at 6 inches ; one was unimproved. 
In 12 vision = form ; 90 per cent, were improved ; seven, 40 improved ; 
four, 20 to 100 per cent. ; six, 200 to 700 per cent. 

Amblyopia. Seven patients, 10 eyes, all were improved. Four, 20 to 
100 per cent. ; six, 200 to 700 per cent. 

Sequelae of Iritis. Two patients, 4 eyes. All were improved; one 
from light perception to 20/70 ; one, 100 per cent. ; two, 200 per cent. 

Intra- Ocular Hemorrhage. One eye, vision improved from light to 
20/20. 

Retinitis Pigmentosa. One patient. One eye improved 100 per cent. ; 
one eye was not improved. 

Retinal Thrombosis. One eye, vision was improved from fingers at 
14' to 6/15 and 0.5 at 12 inches. 

Sequelae Central Retinitis. One patient, two eyes, no improvement. 

Asthenopia. Three eyes. Eecovered. 

Xanthelasma. Two patients. Eecovered. 

Paresis of Ocular Muscles. Two patients. One recovered and one 
was much improved. 

Alopecia of Lids. One patient. Improved. 

Nictitation. One patient. Recovered. 

Pterygium. One eye. No improvement. 

Thus, contrary to the contention of the erudite and lamented Noyes, 
and "most oculists" (Burnett), electricity does seem to justify its claim 
to usefulness in ophthalmic practice. 



CHAPTER X 
HIGH-FREQUENCY CURRENTS. 

A COMPREHENSIVE study of higli-frequeiicy currents, the phenomena 
connected with them, and their remarkable modes of application, has not 
as yet been thoroughly mastered. Literature upon the subject is rapidly 
increasing, but it is a perplexing matter, in the present state of our 
knowledge, to discriminate between the good and the faulty. In present- 
ing the appended chapter on high-frequency currents, no attempt at 
originality has been made ; on the contrary, difficulty was encountered in 
selecting authoritative statements bearing on the subject. 1 

I. Historical Introduction. 

The employment of high- frequency currents for the cure of disease 
was introduced to the profession by D'Arsonval. In 1842 Professor 
Joseph Henry asserted that the discharge from a Ley den jar was oscillatory 
in nature. Later Lord Kelvin, Helmholtz, and others confirmed the view 
advanced by Henry. 

In 1881 W. J. Morton, of New York, published in the Medical Record 
an article entitled "A New Induction Current in Medical Electricity." 

In 1886 and 1887 Hertz and Lodge gave to the world a study, new in 
conception and reasoning, that dealt with experimentation on electric 
waves. 

In 1879 Ward asserted that sparks generated by an induction coil 
operated by a very rapid rotary interrupter were capable of giving 8000 
interruptions per second. 

In 1890 D' Arson val showed that beyond 5000 excitations per second, 
the muscular contractions diminish in proportion to the increase in the 
number of alternations. To support this assertion, he had made an alter- 
nater capable of giving 10,000 alternations per second, and in April, 1891, 
he indisputably demonstrated that a current of high frequency and 
potential could be made to traverse the human body ; increasing the oxi- 
dation consequent upon respiration, diminishing the excitability of the 
tissues, and lowering arterial tension. 

In 1893 Oudin devised the " resonator ;" but it was Tesla who, in 
1891, aroused greatest enthusiasm by the employment of alternators with 

1 Although of late I have largely employed currents of high frequency, I have not 
hesitated to avail myself of the excellent work on " High-Frequency Currents in the 
Treatment of Some Diseases," by Chisholm Williams, published by the Rebman Com- 
pany, New York. 
118 



HIGH-FREQUENCY CURRENTS. 119 

a multiplicity of poles, and, by the introduction of transformers, he was 
enabled to increase the potential to an almost incredible number of volts, 
making possible the assertion and proof that high-frequency and high- 
potential currents could be made to pass through the human body, with 
sufficient energy to light up several incandescent lamps, without the 
slightest danger to the person through whom the currents were passing. 

II. Principles and Apparatus. 

The nature of a discharge is dependent upon the character of the 
electro-motive force producing it, and likewise upon the manner of dis- 
charging it. Thus, when a ball prime conductor of a static machine is 
made to discharge, the discharge occurs in a disruptive manner, consist- 
ing of a series of discharges between the ball and the object at which 
it discharges. When a condenser, as a prime ball conductor, charged 




FIG. 57. Oscillatory nature of the Leyden jar discharge 



with a very high potential, is discharged into a conductor having a cer- 
tain self induction and a slight resistance, there result extremely rapid 
isochronous oscillations, constituting the so-called high-frequency cur- 
rents. Hertz showed the frequency of these oscillations to be hun- 
dreds of millions per second. The alternations of a Ruhmkorff coil 
are about 200 per second, with an electro -motive force of from ten t>\ 
two hundred thousand volts, while the alternations of the high-frequency 
currents are from 100,000 to 1,000,000 volts, depending upon the mean* 
employed. 

The current is obtained from the main, bichromate batteries or from 
an accumulator. A Ruhmkorff coil is required to transform the current 
to one of high tension. The interrupter employed may be the motor- 
mercury interrupter, or the Wehnelt or turbine break. The alternating 
current generated by the coil must be transformed by the condenser into 
a high-frequency current. The condenser consists of two Franklin plates, 
enclosed in a flat box, whose exterior exhibits the small solenoid and the 
spark-gap with connecting screws. Another construction is where two 
Leyden jars are placed behind the spark-gap, and under a bell jar to 



120 



ELECTBO-THEKAPEUTICS. 



dampen the sound. Two conductors arising from the outer tin-foils 
of the Leyden jars end in two terminals, between which a third is inter- 
posed. As is well known, the vibrations from a Leyden jar are oscilla- 
tory in nature (Fig. 57). Where general D' Arsonvalization is required, 
the large and small solenoid are joined to this terminal. 

The following are the principal and most widely used varieties of 
high-frequency current apparatus : 



Morton's 
D' Arson val 
Tesla's 



's . . 1 hi 



Oudin's.. 



high-frequency apparatus. 

f resonator and 
I its varieties. 

MORTON'S " STATIC INDUCED CURRENT " HIGH-FREQUENCY APPARATUS. 

The modus operandi of Morton's 1 apparatus is as follows : The patient 
is directly in circuit with the outside coatings of two Leyden jar con- 
densers in series (Fig. 58). The spark-gap and machine are in multiple 




FIG. 58. Morton's "static-induced current" high-frequency apparatus. 1 

with each other. "With the patient included in circuit in the manner 
shown in the diagram we do not know the value of the inductance and 
resistance offered by him. The arrangement of two condensers of small 
capacity is conducive to the production of oscillatory currents of rela- 
tively high frequency, and such currents will be produced if the patient 
offers a sufficiently low resistance and inductance. 2 

'Journal of Advanced Therapeutics, January, 1903. 

J For a detailed account see articles by Dr. W. J. Morton in The Medical Record, 
pp. 365-371, 395-398, 438-440, April 2, 9, and 16, 1881 ; and pp. 97-104, January 24, 1891. 



HIGH-FREQUENCY CURRENTS. 
D'AESONVAL HIGH-FREQUENCY APPARATUS. 



121 



In the D'Arsonval apparatus 1 (Fig. 59) the terminals of the second- 
ary of an induction coil are respectively connected with one terminal of 
each of two condensers. A spark-gap is placed across the secondary 

, INDUCTION COIL , 




FIG. 59. D'Arsonval high-frequency apparatus. 

circuit. The other two terminals of the condensers are connected with 
the ends of a short coil of a few turns of thick copper wire. One elec- 
trode is connected with one end of the short coil and the other electrode 
is adapted by a sliding contact to include in circuit with the patient any 
desired length of the short coil, and thus regulate the effect produced 
upon him. A straight rod, or tube, of copper may be substituted for the 

x ln Comptes-rendus, vol. cxvi., 1893, pp. 630-633, D'Arsonval (quoted in the 
Second Report of the Committee on Current Classification and Nomenclature, and 
read before the American Electro-Therapeutic Association, September 24, 1903) stated 
in substance (a) that he had communicated to the Societe de Biologie, February 24 and 
25, 1891, the "astonishing fact" that when the frequency of a current was very great 
excitation of the nerves and muscles was not produced ; (6) that the sparking distance 
and therefore potential difference between conductors connected with the ends of 
the short, thick wire coil was greater than "at the spark-gap across the secondary ter- 
minals of the induction coil ; (c) that a very strong oscillating, high-frequency current 
was produced, sufficient to raise a one-ampere incandescent lamp to a white heat when 
in series with two persons completing the branch circuit between the terminal of the 
thick wire coil ; (d) and that he had been able to generate in a branch circuit, includ- 
ing his own body, a current of more than three amperes without any other effect than a 
sensation of heat in the hands. 



122 



ELECTRO-THERAPEUTICS. 



short coil to increase the frequency of the current, by diminishing the 
inductance. A static generator may be substituted for the induction coil. 
Currents of exceedingly high frequency are produced by the D' Arson val 
apparatus. When currents of much higher potential are desired they can 
be obtained from a fine wire coil of relatively many turns, inclosed in a 
glass tube filled with petroleum, and inserted in the thick wire coil. 

That the frequency must be exceedingly high is proved by an experi- 
ment made by Dr. Sheldon. In place of the induction coil for producing 
the spark at the gap, he employed a Holtz machine. 

TESLA'S HIGH-FREQUENCY APPARATUS. 

This is described by its author as follows : t ' The writer's experiences 
tend to show that the higher the frequency the greater the amount of 





FIG. GO. The Tesla transformer. 

electrical energy which may be passed through the body without serious 
discomfort ; * * * * By taking the globe of a lamp in the hand, 
and by bringing the metallic terminals near to or in contact with a con 
ductor connected to the coil [that is to say, connected to one terminal of 
the secondary of an induction coil whose primary is energized by an 
alternating current of very high frequency], the carbon is brought to 




FIG. 63. Glass electrodes. This set of electrodes has been especially designed for convenience in 
changing from one electrode to another. The hard-rubber handle is made very long and provided 
with a universal socket in which any of the electrodes may be fastened or loosened by merely moving 
the ring upon the sleeve which holds the stem of the electrodes. 





FIG. 61. Diagram of the Oudin resonator. The Tesla coil is omitted. The current from the 
induction coil is connected with the inner tin-foil of the Leyden jars. The outer coat of one Leyden 
jar is in connection with the resonator, and is also grounded. The outer coat of the other Leyden jar 
is connected to the handle, H, which, by a sliding movement either in the vertical or the horizontal 
direction, decreases or increases theamount of winding of the resonator. M is the spark-gap for regu- 
lating the amount of current. 

Fio. 62. The Oudin resonator and Tesla coil, with electrode. (Biddle.) 



HIGH-FREQUENCY CURRENTS. 123 

bright incandescence and the glass is rapidly heated. With a 100-volt 
10 c. p. lamp, one may without great discomfort stand as much current 
as will bring the lamp to a considerable brilliancy ; but it can be held in 
the hand only for a few minutes, as the glass is heated in an incredibly 
short time." 1 

In Tesla's apparatus (Fig. 60) the inner tin-foils of the Leyden jars 
are positively and negatively charged from the secondary terminals of the 
Ruhmkorff coil. The outer foils are in connection through the primary 
winding of Tesla's transformer, as is shown in the illustration, and through 
the spark-gap. These high-frequency alternating currents induce alter- 
nating currents in the secondary coil, combining high frequency with 
high tension. 

THE OUDIN RESONATOR. (Figs. 61, 62.) 

Although Hertz had previously employed the phenomenon of reso- 
nance in his experiments, it is to Dr. Oudin that the resonator owes 
its introduction into electro-therapeutics. The apparatus consists of a 
large solenoid of uninsulated copper wire of medium thickness, wound 
spirally about a vertical cylinder of well paraffined wood. The length 
of the wire employed varies from 45 to 60 meters, and its diameter from 
2.5 to 3 millimeters. 

It makes 50 or more turns about a wooden cylinder, 40 to 50 cm. in 
height and 30 cm. in diameter ; while the distance between the spirals is 
about 8 millimeters. 

GLASS VACUUM ELECTRODES. (Figs. 63, 64.) 

These consists of glass tubes of various shapes and sizes, which offer 
a barrier for retarding the entrance of high- frequency currents to the 
part being treated. Tesla's electrodes have as a resisting medium the 
rarefied air contained within them. Those of Dean are made up of a 
series of pieces of thick, hollow glass, in which there is a very high 
vacuum. The glass is sufficiently thick to prevent sparking, thus pre- 
serving the integrity of the vacuum. If the finger be approached to one 
of these glass electrodes when connected to the apparatus, a violet brush 
discharge will be observed between the glass and the finger. This dis- 
charge is produced at the outer side of the tube by induction. The bet- 
ter the contact between the glass and the skin, the less will be the amount 
of brush discharge and of heat produced. The glass tube electrode with 

1 Transactions, American Institute Electrical Engineers, vol. viii. pp. 267-319, 
New York, May 20, 1891 ; and Journal, Institution, Electrical Engineers, vol. xxi. 
pp. 51-163, London, February 3, 1892 ; article on Phenomena of Alternating Currents 
of Very High Frequency, published in the Electrical World, vol. xvii. pp. 128-130, 
New York, February 21, 1891. 



124 



ELECTRO-THERAPEUTICS. 



partial vacuum becomes luminous from the discharge of the current 
through this vacuum, which acts as a conductor ; the luminosity of the 



WAITE &JBA.HTLETT M'F-C Co. 




FIG. 64. Piffard's glass electrode. 



gas is due to its incandescence and tends to heat the glass wall of the tube, 
and these tubes occasionally crack from this cause. 

CATAPHORESIS ELECTRODE. 

The cataphoresis electrode made by K. Schall is most useful for 
applications to large areas, such as the abdomen, chest, and back. It has 
a diameter of 8 inches, and consists of an aluminium disk over which is 
stretched a sheet of parchment. 

Dr. William J. Morton, of New York, long ago found a deficiency 
in vacuum tubes for phoric action, for high-frequency currents. He 
remarks: u A deficiency of all such electrodes is that the bulk of the 
current passes at the periphery of the flat disk. To obviate this I have 
elongated the entering metallic conductor to the region of the flat sur- 
face and have made it a sharp point. 

" Again, if desired, I attach a thin metallic plate of tin-foil or other 
metal upon the outer side of the glass upon its flat side. The diameter 




Fio. 65. Morton's cataphoric electrode. (Waite & Bartlett Manufacturing Co.) 

of this plate is considerably less than the diameter of the circular and 
flat surface of the electrode (Fig. 65). 

"As now arranged the current's action is concentrated to this flat 
surface of the electrode and the cataphoric action is correspondingly 



HIGH-FREQUENCY CURRENTS. 125 

enhanced. But the tin-foil adds to the paiu of the application, and I 
prefer to use the sharp-pointed electrode without the tin-foil condenser." 

Other varieties of electrodes are the condenser (vide Fig. 61, CE, 
supra) and the brush or effluve. 

An effluver or electrode for applying high-frequency currents con- 
sists of a piece of metal, generally cylindrical in form, having on its 
upper surface a series of fine points, from which the discharge jumps to 
the patient. The character of the effluve may be modified by the type 
of effluver used: the greater the number of points, the more thinned will 
be the effluve (vide Fig. 67, infra). 

III. Physical Properties. 

A. INDUCTION EFFECTS. 

B. ELECTRO-STATIC EFFECTS. 

C. DYNAMIC EFFECTS. 

D. RESONANCE EFFECTS. 

A. INDUCTION EFFECTS. 

Induction effects are most intense in their action, as the apparatus 
giving rise to them is of a potent nature. Induction is the effect of an 
electro -magnetic flux on a neighboring body susceptible of an induced 
magnetic saturation, the intensity of the electro-motive force being pro- 
portional to that of the rate of variation of the magnetic changes or 
multiplied by the frequency. Therefore, upon the human body, one 
may bring about a high frequency and a low tension equal to that of a 
high tension, and low frequency on the same or equivalent mass. 

B. ELECTRO-STATIC PROPERTIES. 

Most high-frequency apparatus is so constructed as to permit of the 
production of physical phenomena analogous to the modern static 
machine. For, if we connect the two ends of the short solenoid to two 
plates of insulated metal which are separated from each other, a power- 
ful electro -static field will be created ; which can be demonstrated by 
bringing a Geissler tube between them, when a glow will be manifested, 
as though attached to the terminals of an induction coil. If a similar 
plate of glass, covered on either side with tin-foil, be interposed, and 
each side have attached to it a wire to which an electric lamp is fixed, 
it will be seen that the filament will glow ; proving the presence of 
electrical waves proceeding from an electro-static field. 

C. DYNAMIC PROPERTIES. 

This is proved by the ease with which these currents circulate in an 
open circuit. Imagine a conductor connected to a high-frequency appa- 
ratus by the two poles, and in the middle of this conductor a piece of fine 



126 ELECTKO-THERAPEUTICS. 

wire of high resistance be interposed ; circulate the currents and the wire 
will glow and perhaps fuse. If sealing-wax is employed to couple the 
wires, the current will jump from each wire, producing sufficient heat to 
fuse the wax. 

D. RESONANCE. 

A resonator is an accessory to the apparatus, whose purpose is to 
augment the tension of the current and to create in the vicinity a more 
powerful electro-static field. When two bodies vibrate in unison they are 
said to be syntonous. The Hertz resonator is one of low resistance and 
capable of giving very rapid oscillations, it is likewise of small capacity 
and self-induction. It consists of an induced current formed by a length 
of copper wire so bent as to form nearly a circle, but having two balls at 
the extremities where they are brought near one another. 

This resonator is brought into the field of another vibrator and tuned 
in syntony with the latter ; as soon as the resonator is put in action, 
Hertz's resonator will emit sparks from the two balls. All the other 
resonators are founded on the above principle. 

IV. Methods of Application. 

There are four chief methods of applying high frequency currents, 
as distinguished by D' Arsonval : 

1. Direct application or by derivation. 

2. Indirect application or auto-conduction by the solenoid. 

3. Auto-condensation (Apostoli). 

4. By local application. 

1. DIBECT APPLICATION. 

Connect the patient by two large handles to the ends of the small 
solenoid. The currents will pass through him by derivation ; for by 
virtue of the phenomenon of self-induction, the solenoid offers a great 
resistance, which can be proved by interposing an incandescent lamp in 
the circuit, when it will glow. If the connection between the patient's 
skin and the handles be defective, small sparks will be observed to pass. 
To increase the area of penetration, connect some part or member of the 
patient to one end of the small solenoid, and the other end to a metallic 
plate in the water of the bath, near, but not in contact with the skin. 
If the contact be imperfect, small ulcers may result. With powerful 
installations, when the handles are used after prolonged electrification, 
and with 500 or more milliamperes, heat and tingling may be experienced 
in the hands and arms. The above methods are termed stabile or 
bi- polar. 



HIGH-FKEQUENCY CUKKKNTS. 127 

In the labile method, a fixed electrode connects the patient to the 
solenoid. The other end is manipulated by the physician, who, with an 
insulated handle, is enabled to apply its electrode end to the desired part. 
In approaching the skin with the insulated electrode, sparks appear, and 
the momentary contact produces an erythematous flush. 

The seances should be brief. In systemic affections begin with a 
few minutes' direct auto-condensation or auto-conduction every day. 
Note any subjective symptoms. If the dosage has been in excess, the 
patient experiences a feeling of fatigue. The D'Arsonval milliampere- 
meter should be employed, the range of which should extend to 700 
milliamperes. 

In the local treatment we observe that a reaction is produced at the 
time and continues for some hours thereafter. Thus, in a patch of lupus 
vulgaris, a glass electrode of low resistance connected to the free end of the 
resonator and placed in actual contact with the patient would be used, 
and by a judicious choice of the number of spirals called into play, the 
discharge is reduced to almost nil. After an application lasting five 
minutes, the part feels hot and looks inflamed. The warmth increases 
until the sixth hour, but by the following morning has entirely dis- 
appeared. The inflammation, however, has persisted. After a few 
seances the patch dries up and scales, but the pigmentation remains. 

The treatment may be applied once or twice daily for two weeks, 
then once daily, or every other day, for the same period, reducing the 
number of applications week by week. 

An acute pain, produced by disease, will be augmented at the com- 
mencement of energetic treatment. Defective contacts between the 
patient and the apparatus, or in the apparatus itself, may cause 
unpleasant sensations or shocks. 

2. AUTO-CONDUCTION BY THE SOLENOID. 

By this method (Fig. 66) the patient is not in actual contact with the 
solenoid; his body becomes saturated in the field of the current, i. e., 
sparks may be drawn from him. If a lamp of 20 volts be used to close 
the circuit of a single coil of thick wire, it illuminates with a bright light 
at a distance of more than three feet. 

Place the patient in a large solenoid, and have him join his arms so 
as to form a circuit, which is completed by an incandescent lamp, the 
terminals of which communicate with the hand. The lamp is lighted 
with the induced current in the circuit thus formed. Any conducting 
body placed in this field becomes influenced with induced currents, and 
if a single copper wire of one turn is introduced, the induction produced 
in the latter will be sufficient to light up two lamps of 110 volts mounted 
in series. 



128 ELECTRO-THERAPEUTICS. 

3. AUTO-CONDENSATION. 

In this method the patient is attached to the solenoid in the usual 
way, but the other end is attached to a large metallic plate, brought near 
the patient, but insulated from contact with him. Thus the metal 
plate and the body of the patient form the armatures or coatings of a 
condenser arrangement, having a large electrical capacity, which is 
charged and discharged as the potentials at the extremities of the sole- 
noid vary. The patient lies upon the insulating cushions of the couch, 
the current passing to him either by a handle of bare metal held in the 
hand, or by an electrode applied to the desired part. 

4. LOCAL APPLICATIONS. 

These are especially applicable in the form of brush discharges 
(Fig. 67). Potentials as high as possible are required for these discharges. 
This may be accomplished by employing a secondary coil, which is oil 
immersed, or air insulated. In 1892 Oudin devised his resonator, made 
of an open solenoid of wire, which could be connected as an extension of 
one end of the solenoid of a high-frequency apparatus, and served, when 
carefully adjusted, to raise the potential to such an extent that a long 
brush discharge could be obtained from its free extremity. 

V. Physiological Properties. 

Currents of high frequency and high potential produce no action on 
sensory or motor nerves. When a person or a number of persons are 
placed in the external circuit, and there are interposed incandescent 
lamps of 125 volts, one ampere, the filaments will light up, without pro- 
ducing sensations in the persons in the circuit. With more intense cur- 
rents, only a slight sensation of heat will be perceived at the point of 
entrance and exit. 

H. Lewis Jones controverts the assertion, maintaining that if the 
current in each lamp had been three amperes, it would certainly have 
destroyed life, whether the direct or the alternating current had been 
employed. 

It has been argued that the incandescence occasioned in the lamp 
is caused by the increased resistance in the filament of the lamp, due to 
the very high frequencies, and that a smaller current at a proportionately 
high voltage will make it glow. 

Another theory advanced to account for this phenomenon, is that the 
rushes of current are very considerable while they last, but their dura- 
tion is so very brief, that the total current passing in a given time is rela- 
tively small. Others maintain that a molecular bombardment, rather 
than an electric current, is really the energy dissipated. D'Arsonval 




FIG. 66A. Treatment hy auto-induction. 5 5, secondary terminals of induction coil; B B, 
cords to the auto-conduction cage from the Ourtin resonator; L J, Leyden jar ; J. \ \ L, spark-gap ; 
when sliding in the direction " D," the current suffers a loss in intensity, and vice versa. 




FIG. 67. Treatment by the effluvation method. The condenser electrode, B, is in connection 
with the top of the resonator. Patient is seated upon an insulated platform, holding the electrode, A, 
which is the other pole, from the outer side of the Leyden jar, L J. ( By grounding the outer side of the 
Leyden jar, A, the patient's insulation is unnecessary and better effiuvation is attained.) S. 31. is the 
spark-gap. 



HIGH-FREQUENCY CURRENTS. 129 

affirms that currents of ten times less intensity would be extremely dan- 
gerous if the frequency were decreased from 500,000 to 1,000,000 per 
second, to 100. Tesla inclines to the belief that the harmlessness of these 
currents is due to their lack of penetration of the body at the point of 
contact of the electrodes, but that the current traverses the subject in a 
path perpendicular to the skin and equally over the entire surface. 
D ? Arson val declares that motor and sensory nerves are so constituted as 
to respond to vibrations of a certain frequency, studying the phenomenon 
of neuro-muscular excitement when one increases the number of electrical 
vibrations indefinitely. He has demonstrated that the waves (each of 
which produces a muscular shock if sufficiently distanced) no longer 
produce the same effect if there is an augmentation of their number in 
certain limits per second. Gradually there is a fusion of the contrac- 
tions, which ultimately results in a tetanized condition. In order to 
arrive at this condition, twenty to thirty excitations per second are 
required. The muscle being tetanized, if the number of waves be 
increased, the phenomenon of neuro-muscular excitement is increased 
equally till a maximum is reached, which corresponds to 2500 or 5000 
vibrations per second. From this moment the excitation decreases as the 
number of vibrations per second increase. 

D' Arsonval regards these currents as inhibitory in nature, because 
of the local anaesthesia occurring at the point of entrance of the current, 
which lasts from one to twenty minutes ; and also that the excitability of 
the body to other stimulation is decreased under the influence of these 
currents. He has likewise observed a fall of arterial tension in the dog, 
and lastly, that the sensibility of the skin to galvanism and faradism is 
materially decreased after the passage of high-frequency currents, although 
a greater strength of the former currents can be tolerated, than before 
electrification. 

VI. Applications in Various Diseases. 
TUBERCULOSIS. 

Mr. Chisholm Williams 1 advocates the employment of high-fre- 
quency currents in phthisis. In a series of forty -three cases, he found 
that by the use of these currents there was a marked improvement in 
weight, appetite, and digestive power. For a time the temperature 
became elevated, and the tubercle bacilli in the sputum increased in 
numbers. Later the temperature dropped to normal, the bacilli 
decreased, and the patient's general condition was materially improved. 
In 1903 thirty-nine of the forty-three patients were alive, and in one 
instance the disease appeared entirely arrested. Dr. H. E. Gamlen* 

1 British Medical Journal, October 12, 1901, and October 24, 1903. 

2 Archives of the Rontgen Ray, January, 1906. 



130 ELECTKO-THERAPEUTICS. 

likewise reports excellent results, by the use of high-frequency currents 
in tuberculosis. Dr. Alfred Goss l remarks : "By the method described 
I have treated in the past two years a little over two hundred cases, but 
on account of failure to keep my records accurately previous to June 1, 
1905, I report my cases from that time, and will merely state in regard 
to the previous cases that I had forty-four cases out of eighty recover 
within a period of six months. Since June 1 I have one hundred and 
seventeen cases recorded, with thirty-eight absolute recoveries so far as 
after repeated examinations no tubercle bacilli showed in the sputum. 
They regained their weight and ran a normal temperature. They have 
since been living in various sections of the country and still remain well, 
performing their usual avocations. ' ' 

GOUT. 

In this disease high-frequency currents alone, or in combination with 
other forms of electricity, have been employed. When used alone, auto- 
condensation and auto-conduction have been chiefly employed. These 
currents must not be applied during an acute paroxysm. Low intensity 
and brief duration of stances should first be used, and they should be 
progressively increased. The treatment should be continuously applied 
within short intervals for several months. 

EHEUMATISM. 

This affection has been successfully treated by daily applications 
of high-frequency currents by means of auto- condensation, stances of 
ten minutes' duration. At the end of seven weeks the urine was normal, 
treatment was stopped, pain ceased, appetite returned, and the patient 
regained his natural sleep. In the seven weeks of treatment, his weight 
increased 6 pounds. In chronic rheumatism the greatest benefit is 
derived from high-frequency currents. The same statement is vouched 
for by Gamlen. 1 

OBESITY. 

Foveau de Counnelles was the first to study the effect of high- 
frequency currents on this condition. Boinet and Caillol de Poncy 3 
published a report of a series of cases where the decrease in weight aver- 
aged 14 pounds per month. All of these cases were treated by auto-con- 
duction. In this class of patients, urinary findings show an increased 
excretion of urates and phosphates. 

1 Medical Record, June 9, 1906. 

J Ibid. 

3 Soc. de Biologie, July 31, 1897. 



HIGH-FREQUENCY CURRENTS. 131 



HYSTERIA. 



In these cases the patient gains in general condition, in weight, etc. 
The improvement noted is about on a par with the Weir-Mitchell rest 
cure. In sciatica, neuralgia, tabes dorsal is, and chorea, Gainlen has 
achieved excellent results with high-frequency currents. 1 

LUPUS VULGARIS. 

It would appear that high-frequency currents in this disease behave 
in a manner similar to the X-rays or the Fiusen light. Williams reports 
that twenty applications of five minutes each, over a period of ten weeks, 
suffice to clear up any non-ulcerated small patch of lupus. The effluve, 
the high-vacuum glass electrode emitting X-rays, or the ordinary glass 
electrode may be employed. 

RODENT ULCER AND MALIGNANT DISEASES. 

In rodent ulcer the effluve can be readily and advantageously ap- 
plied. In an interesting case of that disease, Williams records how he used 
his thumb as an electrode, the patient being on the auto- condensation 
couch, and connected to one pole ; the other was connected with the 
operator, and the circuit completed by the latter' s thumb on the ulcer. 
At the end of the first three applications the dry serum became attached 
to the thumb; each additional application seemed to shrink more of the 
ulcer. The hard edges, so resistant at first, disappeared, and for eleven 
months there has been no evidence of a return. The applications are 
painless. Relapses are extremely rare. In 1901 Dr. Allen, of Chisle- 
hurst, 2 published an elaborate report of malignant disease treated with 
high-frequency applications. The results he obtained were most encour- 
aging, some apparent cures being recorded. 

PILES, RECTAL FISSURES, AND PRURITUS ANI. 

In all three of these conditions, high-frequency currents have proved 
most efficient. A special electrode, consisting of a stem with a bare con- 
ical metallic extremity, is employed. Doumer has reported 26 cases of 
hemorrhoids, with more or less successful results. Benefit is most pro- 
nounced in recent acute cases, with marked structural changes. Mr. F. 
J. Bokenham 3 offers a summary of results obtained in two years and a 
half, with currents of high frequency, in the treatment of hemorrhoids, 
rectal fissures, and pruritus ani. The number of cases treated was 118. 
He records 52 as completely cured, 37 as greatly relieved, 18 were 
improved, and the remaining 11 he pronounces failures. He prefers to 

1 Ibid. 

; Medical Electrology and Radiology, vol. v., page 43. 

3 Lancet, July 2, 1904. 



132 ELECTRO -THERAPEUTICS. 

employ high-vacuum glass electrodes. With metal electrodes he uses a 
current of 450 to 500 milliauiperes ; with glass electrodes, 100 to 150 
milliamperes. Duration of each seance about 5 minutes ; he believes 
that no one treatment should ever exceed 15 minutes in duration. 

COLITIS. 

Shenton * remarks that a valuable use of high-frequency currents 
consists in their beneficial effects in mucous and ulcerative colitis. In 
the first case reported by the author, the abdomen was exposed almost 
daily to weak X-rays for a month, but without effect. High-frequency 
treatment was then given on the condenser couch, for a period of ten 
minutes through the hands, followed by a fifteen-minute local applica- 
tion, sometimes from the low tension and sometimes from the resonator. 
This resulted in improvement of the general condition, and gradually the 
diarrhoea, hemorrhage, and pain diminished. The treatment was con- 
tinued nine months and resulted in complete cure. Seven other cases 
subsequently treated, resulted in improvement in the general health, 
increase in weight and appetite, and improvement in sleeping. In all of 
the cases but one, the results were considered satisfactory. 



Hahn z used the high-frequency currents by means of a special nasal 
electrode in the treatment of ozsena. Bordier and Collet in 1902 applied 
high-frequency currents in the treatment of ozsena, and since then Hahn 
has used this method in seven marked cases of the disease. He used an 
Oudin resonator with an electrode similar to that used by Bordier and 
Collet, namely, a metallic rod covered with paraffin or wax, and placed 
in an insulating handle. The electrode may also be enclosed in a glass 
tube, which allows only the tip to project. Care must be taken to apply 
the effluvia to every part of the afiected mucosa. The smaller the sparks, 
the less irritation and reflex action will there be. No cocaine or 
adrenalin was needed before applying the high-frequency current, but 
the patient sneezed a few times after the current was turned on, com- 
plained of burning, slight pain, and lacrymation. But these symptoms 
vanished in two or three minutes if the application was continued. 
After three minutes the electrode was withdrawn and the patient was 
asked to blow his nose, when all the crusts usually came away at once. 
The stance was repeated in from seven to forty-eight hours, and lasted 
usually about fifteen minutes, although it can be made twice as long with- 
out harm. No other treatment, not even irrigation, was used. While the 
author does not allege absolute cures in his seven cases, the improvement 

1 Archives of the Rontgen Ray, August, 1905. 
*Gazzetta degli Ospedali, delle Cliniche, March 5, 1905. 



HIGH-FREQUENCY CURRENTS. 133 

was very marked indeed, and the mucous membrane in some cases 
assumed a more normal aspect. In all cases the crusts disappeared and 
the odor was removed, while the subjective symptoms, including the 
headaches, were almost abolished. He believes that high-frequency cur- 
rents have an antiphlogistic and resolvent action upon the inucosa of the 
nose in oza3na. 

EPILEPSY. 

The following detailed reports of the clinical application of high- 
frequency currents represent some of the more advanced views on the 
therapeutic value of this agent. 

Concerning the treatment of epilepsy, Dr. Samuel G. Tracy J says : 
' i The galvanic and faradic currents of electricity have been used in 
former years, but with little success. If Hughlings Jackson's theories 
regarding the nerve system are correct, it is reasonable to suppose that 
high-frequency, high-potential electric currents will have a beneficial 
effect on the nerve centres, and indirectly on epilepsy. 

" As a rule each patient should be treated every other day, first 
receiving X-radiation from 5 to 10 minutes from a high tube. This is 
placed about 6 to 10 inches above the head, so that the rays strike 
directly upon the anterior and occipital part of the brain (Jackson's 
centres of high level). After the X-radiation the patient should be sub- 
jected to the influence of a high-frequency current, applied over the brain 
for 10 minutes, and for 5 minutes over the spine. In this manner I have 
treated the different forms of epilepsy, but I found the best results were 
obtained by using the combined treatment of X-radiation and high-fre- 
quency currents with small doses of bromides. By this latter method at 
least 25 per cent, of cases of petit mal may be considered tentatively cured, 
20 per cent, of Jacksonian epilepsy, and 12 per cent, of grand mal. All 
cases were improved more or less, not only in regard to the frequency of 
the epileptic seizures, but also in regard to their severity. In addition to 
this the general mental and physical condition was very much improved. 
As these experiments have been continued for less than a year, sufficient 
time has not elapsed to say how much permanent value there is to this 
method of treatment. Nevertheless, such progress has been made in the 
cases treated that I believe we are on the right road to get the best 
results in the treatment of epilepsy. 

11 1 am inclined to believe that the high-frequency currents have 
some chemical effect on the bromide, possibly liberating a larger quantity 
of the bromide as the solution of the salt circulates in the brain, and thus 
the drug in smaller quantities has a more pronounced therapeutic effect 
in controlling the epileptic seizures. ' ' 

'New York Medical Journal, March 4, 1905. 



134 ELECTRO-THERAPEUTICS. 

SKIN DISEASES. 

Dr. Charles \Y. Allen 1 reports 175 cases of various skin diseases 
treated since November, 1901. In chronic eczema he has found the dis- 
charges of vacuum electrodes of decided value in alleviating symptoms 
and in diminishing infiltration. In herpes zoster of the thigh and arm 
with hyperassthesia and neuralgic pain, not only has temporary relief 
been afforded immediately after each application, but the whole course 
of the disease has been shortened and the lesions have promptly healed. 

General effluviation with metallic pointed electrodes, the so-called 
"feather-duster" brush, seems to diminish the pruritus, to shorten the 
attack, and decrease the duration of the entire course in subacute and 
persistently recurring urticaria. Dr. Allen believes that high -frequency 
currents are of decided advantage to those treating skin diseases, in 
conjunction with other measures. They are curative of themselves in a 
restricted class of cases and efficiently meet pruritic symptoms ; but these 
currents are inferior to the X-rays in skin diseases, the best work bMiig 
accomplished when they are used conjointly, as I have frequently seen. 

TRACHOMA. 

In the treatment of trachoma, Stephenson and Walsh - Irelieve a prom- 
ising field has been opened as a result of their work with the X-ray 
irradiation and the high-frequency current. 

In one case, after 22 applications by the high-frequency current a case 
of trachoma was apparently cured. A 12- inch spark-coil (Cox) was run 
from the main connection with a D'Arsonval high-frequency apparatus. 
One end of the solenoid was earthed, while the other was connected with 
a vulcanite electrode, with which the closed eyelids were gently massaged. 
A small brush discharge of about half an inch was obtainable from the 
electrode, which would probably have acted upon the trachoma equally as 
well without actual contact of the electrode with the lids. So far as can 
be ascertained, this is the first application of the high-frequency current 
to the eye. By this means, as with the focus tube, more improvement 
has l>een effected than could have been expected from the prolonged use 
of escharotics. 

DULNESS OF HEARING AND SUBJECTIVE NOISES. 

Dr. ,T. G. ConuaP says in reference to dulness of hearing and the 
occurrence of subjective noises : "The cases were of a class not readily 
influenced by ordinary methods of treatment. The types selected were : 
(1) chronic dry catarrh of the middle ear with secondary labyrinthine 

1 Medical Record, February 20, 1904. 

1 Medical Press and Circular, No. 7; Progress of Medical Science, 1903. 

8 Journal of Laryngology and Rhinology, August, 1904. 



HIGH-FREQUENCY CURRENTS. 135 

involvement ; (2) chronic dry catarrli of the middle ear without marked 
labyrinthine involvement ; (3) sclerosis of the middle ear ; (4) post- 
suppurative conditions of the middle ear (the purulent process having 
ceased), leaving a cicatrix or a dry perforation with or without cal- 
careous deposit in the tympanic membrane ; (5) primary labyriuthitis 
(traumatic); (6) tinnitus without dulness of hearing. In all the cases 
both ears were involved, one ear generally being worse than the other. 
Results : 1. Six cases. No improvement in the hearing of any of 
them. In four the tinnitus persisted ; two thought the noises were slightly 
lessened, but were not at all certain. 2. Fourteen cases. In ten, no 
improvement in hearing ; one was worse ; two noted a slight improve- 
ment in the hearing. One patient said she heard much better, but the 
improvement was not appreciable by the tests applied. Of the ten 
patients who complained of tinnitus, eight reported an improvement ; 
two of these said they were very much better. In one case the noise dis- 
appeared entirely in one ,ear for six weeks, when it recurred. 3. Five 
cases. One patient said she heard better, but did not respond to tests ; 
four reported an improvement in the hearing, confirmed with the watch, 
and improvement in the tinnitus. 4. Seven cases. Four reported a 
slight improvement in hearing, and four or five who had tinnitus reported 
improvement. 5. One case. No benefit. 6. One case. No benefit. 
The author urges the importance of technic in the electrical treatment of 
these cases. The common method of applying the current is by means 
of the effluve (sjjray). This method was adopted in the earlier cases, 
but was found unsatisfactory. The method of using a condenser elec- 
trode in each ear was substituted and gave better results, probably 
because the current is more completely concentrated on the ears. 

GONORRHCEA. 

Gamlen * treated a rebellious case of gonorrhoea by high-frequency 
currents, by means of a bougie connected with the terminal on the top of 
the resonator. At the same time, general high-frequency currents were 
administered. Sixteen of these combined treatments effected a cure. 
Local treatment was given every second day ; duration of each treatment 
was five minutes. He also mentions the case of a young woman, with a 
history of gonorrhoea of three weeks' duration. The usual medicinal 
treatment proved futile ; high-frequency treatment was instituted and a 
vaginal glass electrode was employed. ' ' After the first few applications, ' ' 
says Gamlen, i ' the irritation, and later the discharge, gradually subsided. 
Fourteen applications effected a complete cure. ' ' 

1 Archives of the Rontgen Ray, February, 1906. 



136 ELECTEO-THEEAPEUTICS. 

Fulguration. 

Fulguration, sideratiou, or lightning treatment, is a method of 
therapy introduced to the profession by Keating-Hart of Marseilles, and 
has for its object the treatment of carcinoma by electro-surgical means. 1 
The procedure is both surgical and electrical; as treatment by sparks of 
high frequency and of high tension would be impracticable if used alone. 
To secure favorable results from high-frequency currents by itself would re- 
quire many and long exposures, whilst the elimination of toxic products 
would so impair the patient's vitality as to lead to dangerous consequences. 

Surgical interference must always precede electrical treatment. 
The neoplasm is to be removed as far as its junction with the healthy 
tissue, the two operations may be carried out at the same time, as general 
anaesthesia is demanded for both procedures. 

A. APPARATUS. 

This is the apparatus that is used in the production of high-fre- 
quency currents, and the sparks are obtained from the extremities of the 
small solenoid or resonator of Oudin. 

The installation required will be as follows : 

( Main. 

1. Source of electricity < Dynamo. 

(. Accumulator. 

2. Switch-board with rheostat, amperemeter, fuse, etc. 

3. A 16-inch (40cm.) coil, very rapid interrupter, or a transformer 

with closed magnetic circuit used with an alternating current. 

4. A condenser of variable capacity. 

5. Oudin' s resonator. 

6. A forced draught, from a foot-bellows, or from a carbonic acid 

cylinder, etc. 

7. A De Keating-Hart electrode. 

8. An operating table of wood. 

B. TECHNIC. 

The two methods of application are the unipolar and the bipolar. 
By the former method a shower of sparks passes from the resonator to 
the patient, who is connected to earth. In the bipolar method the 
patient is connected to one end of the solenoid, and thus a much more 
powerful spark passes between the electrode held by the operator and 
the patient. The resulting shock is much more violent and causes severe 
muscular contraction. This may be obviated, however, by including 
only the neoplasm itself between the electrodes. 

Keating-Hart prefers the unipolar method, asserting that the bipolar 

1 Archives of the Rontgen Ray, Vol. 13, No. 5, October, 1908. 



HIGH-FREQUENCY CURRENTS. 137 

spark is more destructive aud causes such violent contractions as to 
endanger the surrounding vital organs. 

Both the effluve and the shower of sparks arise at the ends of the 
resonator. The former appears as a fine violet rain, which causes no 
pain or destruction, and in all probability stimulates the vitality of the 
carcinoma ; whilst the sparks, appearing as white flashes, if of insufficient 
quantity and not accompanied by excision, also increase the growth. 

After the patient has been anaesthetized, the surgeon incises the 
tissues, so as to lay bare the offending growth, without separating. He 
then showers upon it a stream of the strongest sparks, his object being to 
produce a marked vaso-constriction, as its prolonged action tends to 
modify its density and to determine the line of demarcation between 
normal and pathological tissue. It also decreases capillary hemorrhage, 
and thus reduces the possibilities of re-inoculation. 

The growth should now be excised. Even inefficient extirpation is 
sufficient if followed by f ulguration. Excision of the tongue, rectum, and 
uterus are well suited to this method. 

C. DOSAGE. 

This can only be gauged by the experience of the operator. The 
strength of the sparks varies widely ; by constantly using the same appa- 
ratus the operator learns to know the appearance of the spark, its noise, 
length, thickness, etc. In addition he may obtain four different effects, 
either isolated or combined. Two of these, destruction and heraostasis, 
are direct ; two are indirect effects, namely, lymphorrhoea and the reaction 
of the underlying tissues. Analgesia is a consequence of these. 

In capillary hemorrhage, the haemostatic effect is of most use. After 
applying the sparks for some time, the wound is covered by a thin dark 
layer which is readily removed by the slighest rub. This coagulum is 
composed of a vast aggregation of minute blood-clots, formed at the 
openings of the capillaries. 

The unipolar spark has no very deep destructive action. As the 
sparks proceed from a point conductor, over the expanse of a large 
surface, their energy will decrease with the square of the distance. Some 
heating effect will naturally be associated with the spark proper. By 
prolonging the bombardment at one point, one can see the formation of a 
burn and smell the searing tissue. Pathological tissue is far less 
resistant to this destructive action than is normal tissue, and it is inter- 
esting to note, that, after prolonged "sparking, "neoplasms may be de- 
stroyed to the depth of several centimetres, whilst the healthy tissues may 
be slightly, if at 'all, affected. 

The destructive effect of the sparks may be limited by diminishing 
their length and the duration of application. For the same spark the 



138 ELECTED- THERAPEUTICS. 

superficial destructive power and the burning effect increase the nearer 
the electrode is placed to the tissue ; whilst a spark of maximum length 
is capable of producing great violence of shock and of penetrating deeply 
the tissues. 

Previous mention has been made of the production of lymphorrhoea. 
By this term we refer to a phenomenon which appears during or im- 
mediately following an operation ; increasing during the first twenty-four 
hours and then diminishing. A few days later there is an exudation of 
sero-purulent fluid with the separation of a slough. Lymphorrhoea is 
greatest when the long spark is employed. Microscopically the exuded 
liquid is filled with many polyneuclear leucocytes. The occurrence of 
this sero-purulent flow is the safety-valve guiding the operator; its 
suppression coincides with extreme rise of temperature. 

Upon the underlying structures, fulguration may exhibit local and 
general effects. The former is the rapid cicatrization from the periphery 
to the centre. With the separation of the slough, granulations quickly 
appear, the larger cavities become obliterated by dense fibrous tissue 
formation, and the cutaneous scar is a good one. Surrounding nodules at 
some distance from the main neoplasm seem inhibited for one or two 
weeks, and often longer. On the other hand, ulcerated nodules of the 
skin have been seen to have cicatrized or to completely disappear without 
being touched by the spark. So also with cancerous glands, some of 
them having undergone a kind of fibrous degeneration, others exhibiting 
a rapid caseous or purulent degeneration. As a rule, secondary glandu- 
lar formations are less dangerous than separate nodules, they frequently 
decrease in size or disappear with fulguration of the primary growth ; at 
first thought, therefore, it seems logical to remove them at the earliest 
operation, treating later those glandular metastases that failed to disap- 
pear after the initial fulguration 5 but, besides avoiding a second operation, 
the purulent discharge above mentioned would tend to render such a 
later procedure less aseptic ; it is therefore a part of wisdom to remove 
at once any diseased glands and to fulgurate their site. The effect of the 
spark on normal and pathological tissue and on micro-organisms is, as 
yet, sub judice. The lymphorrhoea assists, by draining the lymphatics of 
migratory cancer-cells, and by bringing to the area of the disease a 
myriad of beneficent leucocytes. At the same time it carries with it 
or destroys colonies of unfixed cells. 

''What is the cause, then,'' asks De Keating-Hart, "of the inhibition 
of the growth of these larger nodules after fulguration ? Although in my 
first operation, surgical ablation was often far from complete, I got 
results better than could have been hoped for. I have had cases which 
remained cured for years, although neoplastic nodules have remained, as 
proved by subsequent clinical examinations." He then cites a number of 
cases, not the least interesting of which and illustrative of the others, 
are the ones here subjoined : 



AIR PUMP 
HEATIN& RES. 




FIG. 67 A. Diagrammatic view of Keating-Hart's method of fulguration. The illustration shows 
the passage of the current from the resonator to the electrode, and also the connection with this electrode 
of a spiral tubing through which is pumped a constant stream of cool sterilized air, so as to decrease 
the intensity of the temperature of the tissue. (Arch. d'Electricite Medicale.) 



ELECTRODE /v CURVED 

GHiS^fiSi 

ELECTRODE / CURVED 

^^^^^^^^^IBH 

ELECTRODE. RIGHT ANGLE (SHORT) 




ELECTRODE. RIGHT ANGLE (LONG) 



FIG. 67B. Keating-Hart's electrodes for fulguration. 



HIGH-FREQUENCY CURRENTS. 139 

1 i A woman suffered from a recurrent growth of the breast after two 
surgical operations with numerous secondary cutaneous cancerous nodules, 
with swollen glands in the axilla, and swelling of the arm and hand, 
accompanied by profound cachexia. After curetting the tumor and 
applying fulguration the lesions cicatrized, the swelling of the arm went 
down, and perfect health returned. Now, more than a year later, one 
can feel a neoplastic growth not completely destroyed, but quite inactive. ' ' 

Of a case of rectal carcinoma which had been treated hy curettement 
and fulguration, he remarks: 

1 ' Even after a year or more of local and general good health should 
a torpid recurrence appear, one is able to repeat the treatment in even 
more favorable circumstances than before. If by fulguration once a 
year, or even less frequently, one can keep in good condition a patient 
otherwise doomed, one is surely justified in using this treatment. I have 
had a sufficient number of similar cases to feel warranted in recommend- 
ing fulguration for the treatment of cancer. ' ' 

It is as yet too early to determine whether the cure from this technic 
is more permanent, and recurrences rarer, than after the usual surgical 
operation. Czeruy has given the method a thorough trial in a large number 
of cases 1 and believes fulguration represents an important advance in the 
treatment of cancer. He observes the advantage of greater certainty and 
more rapid action in comparison with radium and X-ray irradiations; at 
the same time questioning the power of this new therapy to effectively 
influence the more deeply situated neoplasms. Czeruy has modified 
Keating- Hart's teclmic so as to include fulguropuncture and fulgurolysis 
with bipolar applications of high-tension and high-frequency currents. 

To epitomize, the Keating-Hart technic may be described as follows: 

Apply as powerful an electric spark as possible from a metal elec- 
trode at a distance of 1 to 2 inches (2, 3 or 4 cm.), focussing the spark 
at different points in the cancer, the entire exposure lasting from 5 or 10 
to 40 minutes. The radiated, softened cancer substance is then scraped 
out, and fulguratiou is then applied again for 10 or 15 minutes to the raw 
surface to destroy any possible remaining nests. The apparatus can be 
attached to the Rontgeu apparatus, using a 50 cm. inductor and Wehnelt 
interrupter. The electricity is conducted to a petroleum condenser with 
a spark -interrupter and solenoid. This is connected with an Oudin 
resonator, which can be arranged to send out a spark-brush from 3-7 
inches (10 to 20 cm.) long. The total amount of electricity is not very 
large, so the actual electro-chemical action is comparatively slight. It 
seems to stimulate the connective tissue to granulation and normal growth. 
The powerful outward current of lymph that follows fulguration washes 
out the cancer cells and brings an army of phagocytes to the spot, but if 
any cancer-cells remain unaffected by the fulguratiou they are liable to 
continue to proliferate. 

1 Miinchener medizin. Wochenschr., vol. Iv, No. 6, Feb., 1908. 



PART II 

THE RONTGEN RAYS IN DIAGNOSIS 



Historical Introduction. 

THE discoveries made and the achievements wrought in the domain 
of electricity are the recorded efforts of determined and conscientious 
minds of all ages. From the remotest periods of the world's history the 
mysterious phenomena of electricity have arrested attention and invited 
thought from searching inquirers, and slowly but surely the hidden 
secrets of this subtle force of nature have been steadily unfolded, until 
to-day the mighty achievements ascribable to it confront us on every side, 
offering a telling contrast to the methods pursued a few centuries ago, 
when men with crude appliances and still cruder ideas led the van in ex- 
perimental inquiry. 

To Otto von Guericke, the world owes a debt of gratitude for hia 
successful labors in inventing, in 1650, the air-pump and in ingen- 
iously applying it to the laws of science. In 1740 Abb6 STollet em- 
ployed the air-pump and continued the studies commenced by von 
Guericke. It remained for Sir W. Snow Harris, in 1834, to formulate 
boldly the statement, that the length of the spark which an electric 
machine will give in the air varies as the inverse ratio of the pressure of 
the gas. 

In 1838, the immortal Faraday challenged the world' s admiration 
with his experiments in electricity, and simultaneously his celebrated 
confrere, Heinrich Geissler, made memorable that scientific epoch, by im- 
proving on the efforts of Faraday in his study of electric glow discharges. 
The principles of and the laws governing electric science were being 
surely evolved, when in 1840 Clerk Maxwell turned the search-light on 
this special department of science, and gave to the world the electro- 
magnetic theory of light. 

Sir William Thomson (now Lord Kelvin), not unmindful of the 
laborious researches of Sir W. Snow Harris, determined to make a pro- 
found study of the relation existing between gas pressure and spark 
length, and in 1860 he gave to science the absolute electrometer, an in- 
vention that at once brought his name into commanding prominence. 
The substitution of the Buhmkorff coil by cells was the very original 
thought that occupied the attention of Gassiot. With a battery con- 
sisting of more than 3500 cells, this celebrated French physicist proved 
140 



THE RONTGEN RAYS IN DIAGNOSIS. 141 

conclusively that a vacuum tube glowed incessantly when placed in the 
path of its circuit, and in 1865, Hermann Spreugel invented the mercury 
air-pump, an instrument devised for the purpose of producing very high 
rarefactions, with a great degree of rapidity. 

In 1869, HittorPs name became familiar for experimentations along 
these lines, and the same work was largely followed by Goldstein in 1876. 
It was during the latter year that the brilliant researches of Gassiot were 
being still further prosecuted. In 1877, a coterie of scientists were eager 
to take up the work where Gassiot had left off; not the least conspic- 
uous among these were Warren de la Rue, Hugo Miiller, and W. Spottis- 
woode. 

From 1877 to 1879, investigators were making extended studies and 
investigations into the theories already advanced, and perfecting with 
unremitting energy the practical points previously deduced. In the 
latter year the celebrated Sir William Crookes startled the world by his 
announcement that matter was radiant. It was he who declared that the 
particles that were shot oif from the cathode ray possessed strange and 
remarkable properties. 

In 1883, Wiedemann and J. J. Thomson continued these studies and 
declared these particles to be ether disturbances of very short wave 
length. The study was continued by Professor Hertz at Bonn, leading 
to an investigation of high vacua discharge experiments. The work was 
continued by his assistant, Professor Lenard, who in 1894 proved the 
possibility of cathode rays passing through the walls of a vacuum tube. 
Perrin, in France, and Elster and Geitel in Germany, made searching 
studies into the latter subject. 

It was in 1895, that Professor Rdntgen was experimenting with 
Lenard and Crookes tubes when an unusual phenomenon met his gaze. 
His tube was completely enveloped in an opaque cover, when a near-by 
paper containing a fluorescent substance exhibited a most pronounced 
visible glow ! How could the phenomenon be explained ? The rays 
offered a triumphant resistance to the action of the magnet. These were 
the rays so indispensable to the photographer's art; the rays that were 
destined to revolutionize many preconceived notions in medicine and 
surgery. A new radiation had burst forth at the touch of genius ; a new 
science had come into being. 

Wilhelm Conrad Rontgeu was born in Lennep, Province of the 
Rhine, Germany, March 27, 1845. At an early age the boy showed a 
remarkable aptitude for study, and in 1870 he was graduated as a Doctor 
of Philosophy from the University of Zurich. Seeing that the youth 
gave promise of a bright career, Professor Kundt took a lively interest 
in the young man, and in 1873, when Kundt was elected to a chair at the 
University of Wiirzburg, the young scientist accompanied him, and at 



142 ELECTRO-THERAPEUTICS. 

Professor Kuudt's promotion to the University of Strasburg, Professor 
Rdutgen became his assistant. In 1875, Professor Routgeu was made 
Professor of Mathematics and Physics in the Agricultural Academy at 
Hohenheim, retiring from the institution to return to Strasburg just 
one year later. In 1870, he accepted a call as Professor and also as a 
Director of the Department of Physics at the University of Giesseu ; he 
likewise accepted a similar position at the University of Wiirzburg, 
the latter office he still holds. 

The labors of Professor Rdutgen have been manifold ; he has had 
published his investigations on isothermal crystals, solar calorinietry, 
dust figures, aneroid barometry, absorption of heat by various vapors, 
etc. During the past decade his studies have been almost exclusively 
devoted to problems in electricity. Space forbids naming even a tithe of 
the honors that have been showered upon this celebrated scientist. Re- 
quested by the German Emperor to demonstrate his discovery at the 
Palace at Potsdam, the Emperor decorated him with a Crown Order of 
the Second Class. The University of Munich presented him with a pro- 
fessorship in recognition of his immortal discovery. He was awarded 
the Barnard medal from the National Academy of Sciences at the com- 
mencement exercises of Columbia University, New York City, and he 
also received the Nobel prize in 1901. 

The Comparative Study of the Properties of the Cathode and the 
Rontgen Rays. 

% 
CATHODE RAYS. 

Production. Much discussion has arisen as to the true character of the 
cathode rays. One school of philosophers declare that they are not rays 
of light, but merely a stream of molecules proceeding from the cathode ; 
others adhere to the view that these rays are analogous to ordinary light 
rays, and represent some process occurring in the atmospheric ether. 
Nevertheless the fact remains that, for their production, it is essential to 
have a certain degree of vacuum in the tube. If this degree of vacuum 
be increased, the production of cathode rays is no longer possible, and 
when the tube is as completely exhausted as is possible, the production of 
X-rays occurs. Cathode rays can be produced only within the walls of 
the glass tube, and must be studied outside of the tube by the introduc- 
tion of Lenard's aluminium window. 

Eadiability. Professor Hertz was the first to demonstrate authorita- 
tively that thin sheets of metal were transradiable, and Lenard showed 
the phenomenon to be true of thin layers of other substances opaque to 
light. Gold, silver, and aluminium foil allowed the passage of the rays 
without suffering loss of any of their intensity. With gases, it was found 



THE BONTGEN BAYS IN DIAGNOSIS. 143 

that the power of penetration varied inversely as the density, /. <?., the 
greater the density the less the penetrability. AVater was found to be 
transradiable only in extremely thin strata. 

Fluorescence and Phosphorescence. Experimentation has proved that 
the phosphides of the alkaline earths, calc spar, and uranium glass glow 
brilliantly when near the aluminium window. Salts of manganese, cad- 
mium, strontium, and lithium luminesce brightly. Liquids are inactive. 
A rather curious fact is, that the sulphate of quinine in solution is only 
slightly excited, but the same salt in the solid state offers a most bril- 
liant glow of a deep blue color. Lenard affirms that the platino-cyanides 
exhibit colors, similar to those that are produced under the influence of 
the ultra-violet rays. 

Reflection, Refraction, and Polarization. In the vacuum tube the 
cathode rays appear to be reflected and to behave in the same manner as 
rays of light. Nothing definite has been determined regarding the polar- 
ization of these rays. 

Chemical and Photographic Effects. The cathode rays possess a most 
energetic chemical action on the alkaline haloids, and on some of the 
haloids of the earths. Thus lithium chloride suffers a change to violet, 
whilst sodium chloride can be made to change to either a yellow or a gray 
color. Upon heating, the former is converted into a red color ; the latter 
blue. The cathode rays act energetically on photographic papers and 
plates ; thus iodine paper is quickly converted to a pronounced blue on 
exposure to the rays. 

Physiological Effects. Neither the eye nor the skin is affected by the 
action of the cathode ray; a characteristic odor and taste are produced, 
but by some authorities these are ascribed to the presence of ozone. 

Theories. The theories advanced to explain the cathode rays are the 
hypotheses put forth by the leading exponents of the English and German 
schools of philosophers. The former physicists incline to the belief that 
the cathode rays are streams of electrified molecules that are shot off from 
the cathode ; in contradistinction to the German scientists, who hold that 
these rays are manifestations of ethereal vibrations; defending this state- 
ment with the results of Lenard' s investigations, and declaring, with that 
scientist, that cathode rays are propagated through a vacuum in straight 
lines, and so void of all matter that through them an electric spark can- 
not be made to pass. 

Jaumann's theory, which brings into the discussion the subject of 
longitudinal waves, has received some support. He asserts that when 
these rays are incident at right angles there is caused a high discharging 
effect, showing a large longitudinal component. This theory gains cor- 
roboration in a magnetic field. In accordance with this investigator's 
views, these rays can only be normally reflected when the force applied 



144 ELECTEO-THEEAPEUTICS. 

is parallel to the reflecting surface. Space forbids the presentation of 
many other ingenious theories, advanced by Wiedemann, Hertz, Gold- 
stein, Prout, and J. J. Thomson. 

EONTGEN BAYS. 

Production. The new radiation that form of energy called the 
Eontgen rays or the X-rays, requires for its production a highly exhausted 
discharge tube. It must be borne in mind that the essential factor in the 
generation of the Eontgen rays is that the electric discharge must be made 
to take place in a high-vacuum tube, such as the Crookes tube j other 
circumstances, as the character of the coil or dynamo, being matters of 
minor consideration. Again, if we take Geissler tubes, which are bulbs 
in which the air is only partially exhausted, we obtain what is known 
as a low vacuum, and it is difficult, or indeed impossible, to generate 
Eoutgen rays from such a discharge apparatus. The Eontgen rays re- 
quire the one-millionth part of atmospheric pressure. 

Radidbility and Penetrability. The peculiar power possessed by the 
Eontgen rays, of penetrating substances opaque to ordinary light or 
cathode rays, has been shown by Professor Eontgen to be largely de- 
pendent upon the relative density and thickness of the substance under 
examination. 1 In an elaborate exposition in his first communication, 
he says : 

u Sheets of hard rubber several centimetres thick still permit the 
rays to pass through them. Glass plates of equal thickness behave quite 
differently, according as they contain lead (flint-glass) or not ; the former 
are much less transparent than the latter. If the hand be held between 
the discharge tube and the screen, the darker shadow of the bones is seen 
within the slightly dark shadow-image of the hand itself. "Water, carbon 
disulphide, and various other liquids, when they are examined in mica 
vessels, seem also to be transparent. That hydrogen is to any considera- 
ble degree more transparent than air, I have not been able to discover. 
Behind plates of copper, silver, lead, gold, and platinum the fluores- 
cence may still be recognized, though only if the thickness of the plates 
is not too great. Platinum of a thickness of 0.2 mm. is still transparent ; 
the silver and copper plates may even be thicker. Lead of a thickness 
of 1.5 mm. is practically opaque; and on account of this property this 
metal is frequently most useful. A rod of wood with a square cross- 
section (20 x 20 mm.), one of whose sides is painted white with lead 
paint, behaves differently according as to how it is held between the 

1 In this and the succeeding paragraphs the quotations have been taken from 
" Riintgen Rays;" embracing Professor Rontgen's original communications to the 
Physikalisches Institut der Univereitiit, of Wiirzburg, and translated by George F. 
Barker, LL.D.; Harper and Brothers, Publishers. 



THE RONTGEN RAYS IN DIAGNOSIS. 145 

apparatus and the screen. It is almost entirely without action when the 
X-rays pass through it parallel to the painted side ; whereas the stick 
throws a dark shadow when the rays are made to traverse it perpendicular 
to the painted side. In a series similar to that of the metals themselves, 
their salts can be arranged with reference to their transparency, either 
in the solid form or in solution. 

u The experimental results which have now been given, as well as 
others, lead to the conclusion that the transparency of different substances, 
assumed to be of equal thickness, is essentially conditioned upon their 
density ; no other property makes itself felt like this, certainly to so high 
a degree. 

"The following experiments show, however, that the density is not 
the only cause acting. I have examined, with reference to their trans- 
parency, plates of glass, aluminium, calcite, and quartz, of nearly the 
same thickness ; and while these substances are almost equal in density, 
yet it was quite evident that the calcite was sensibly less transparent than 
the other substances, which appeared almost exactly alike. No particu- 
larly strong fluorescence of calcite, especially by comparison with glass, 
has been noticed. 

"All substances with increase in thickness become less transparent. 
In order to find relation between transparency and thickness, I have 
made photographs in which portions of the photographic plate were 
covered with layers of tin-foil, varying in the number of sheets super- 
posed. Photometric measurements of these will be made when I am in 
possession of a suitable photometer. 

' ' Sheets of platinum, lead, zinc, and aluminium were rolled of such 
thickness that all appeared nearly equally transparent. The following 
table contains the absolute thickness of these sheets measured in milli- 
metres, the relative thickness referred to that of the platinum sheet, and 
their densities : 



Thickness. 
Pt 0.018 mm 


Relative Thickness. 
1 


Density. 
21.5 


Pb 0.05 mm 


3 


11.3 


Zn 0.10 mm , 


6 


7.1 


Al 3.5 mm. 


. 200 


2.6 



"We may conclude from these values that different metals possess 
transparencies which are by no means equal, even when the product of 
thickness and density are the same. The transparency increases much 
more rapidly than this product decreases. ' ' 

Fluorescence and Phosphorescence. In his first communication Pro- 
fessor Rontgen discourses at length on the fluorescent effects of the new 
ray, and states its effect on barium platino-cyanide, calcium sulphide, etc. 
10 



146 ELECTBO-THERAPEUTICS. 

The amount and color of the radiations emitted would seem to be entirely 
dependent upon the character of the substance under examination. In 
this connection he wrote : 

"If the discharge of a fairly large induction coil be made to pass 
through a Hittorf vacuum-tube, or through a Lenard tube, a Crookes 
tube, or other similar apparatus which has been sufficiently exhausted, 
the tube being covered with thin, black card-board which fits it with tol- 
erable closeness, and if the whole apparatus be placed in a completely 
darkened room, there is observed at each discharge a bright illumination 
of a paper screen covered with barium platino-cyauide, placed in the 
vicinity of the induction coil, the fluorescence thus produced being en- 
tirely independent of the fact whether the coated or the plain surface is 
turned toward the discharge tube. This fluorescence is visible even when 
the paper screen is at a distance of two metres from the apparatus. It is 
easy to prove that the cause of the fluorescence proceeds from the dis- 
charge apparatus, and not from any other point in the conducting circuit. 

"The most striking feature of this phenomenon is the fact that an 
active agent here passes through a black card-board envelope, which is 
opaque to the visible and the ultra-violet rays of the sun or the electric 
arc ; an agent, too, which has the power of producing active fluorescence. 
Hence we may first investigate the question whether other bodies also 
possess this property. 

"We soon discover that all bodies are transparent to this agent, 
though in very different degrees. I proceed to give a few examples : 
Paper is very transparent ; behind a bound book of about one thousand 
pages I saw the fluorescent screen light up brightly, the printer's ink of- 
fering scarcely a noticeable hinderance. In the same way the fluorescence 
appeared behind a double pack of cards; a single card held between the 
apparatus and the screen behind being almost unnoticeable to the eye. 
A single sheet of tin-foil is also scarcely perceptible ; it is only after sev- 
eral layers have been placed over one another that their shadow is dis- 
tinctly seen on the screen. Thick blocks of wood are also transparent, 
pine boards two or three centimetres thick absorbing only slightly. A 
plate of platinum about fifteen millimetres thick, though it enfeebles the 
action seriously, did not cause the fluorescence to disappear entirely. 

* * * * The fluorescence of barium platino-cyanide is not 
the only recognizable effect of the X-rays. It should be mentioned that 
other bodies also fluoresce; such, for instance, as the phosphorescent 
calcium compounds, then uranium glass, ordinary glass, calcite, rock-salt, 
and so on." 

Reflection, Refraction, Polarization, and Interference. The earlier ef- 
forts made, tended to show that the Rontgen rays defied reflection, but 
later investigations have conclusively proved that a reflection, similar to 



THE KCXNTGEN BAYS IN DIAGNOSIS. 147 

that diffuse reflection obtained from the surface of ground glass, could be 
demonstrated. It has likewise been shown that reflection is largely de- 
pendent on the character of the substance composing the surface. More 
recently Carmichael, of Lille, succeeded in reflecting X-rays through the 
agency of steel mirrors. The value of his experiment has not been deter- 
mined. In his first paper upon the X-rays Professor Bontgen said : 

' ' After I had recognized the transparency of various substances of 
relatively considerable thickness, I hastened to see how the X-rays be- 
haved on passing through a prism, and to find out whether they were 
thereby deviated or not. 

" Experiments with water and with carbon disulphide enclosed in 
mica prisms of about 30 refracting angle showed no deviation, either 
with the fluorescent screen or on the photographic plate. For purposes 
of comparison, the deviation of rays of ordinary light under the same 
conditions was observed ; and it was noted that in this case the deviated 
images fell on the plate about 10 or 20 millimetres distant from the direct 
image. By means of prisms made of hard rubber and aluminium, also of 
about 30 refracting angle, I have obtained images on the photographic 
plate in which some small deviation may perhaps be recognized. How- 
ever, the fact is quite uncertain ; the deviation, if it does exist, being so 
small that in any case the refractive index of the X-rays in the substances 
named cannot be more than 1.05 at the most. With the fluorescent 
screen I was also unable to observe any deviation. 

1 ' Up to the present time experiments with prisms of denser metals 
have given no definite results, owing to their feeble transparency and 
the consequently diminished intensity of the transmitted rays. 

' ' With reference to the general conditions here involved on the one 
hand, and on the other to the importance of the question whether the 
X-rays can be refracted or not on passing from one medium into another, 
it is most fortunate that this subject may be investigated in still another 
way than with the aid of prisms. Finely divided bodies in sufficiently 
thick layers scatter the incident light and allow only a little of it to pass, 
owing to reflection and refraction ; so that if powders are as transparent 
to X-rays as the same substances are in mass equal amounts of ma- 
terial being presupposed it follows at once that neither refraction nor 
regular reflection takes place to any sensible degree. Experiments 
were tried with finely powdered rock salt, with fine electrolytic silver 
powder, and with zinc dust, such as is used in chemical investigations. 
In all these cases no difference was detected between the transparency of 
the powders and that of the substance in mass, either by observation 
with the fluorescent screen or with the photographic plate. 

11 From what has now been said it is obvious that the X-rays cannot 
be concentrated by lenses ; neither a large lens of hard rubber nor a glass 



148 ELECTRO-THERAPEUTICS. 

lens having any influence upon them. The shadow- picture of a round 
rod is darker in the middle than at the edge ; while the image of a tube 
which is filled with a substance more transparent than its own material is 
lighter at the middle than at the edge. 

" The question as to the reflection of the X-rays may be regarded as 
settled, by the experiments mentioned in the preceding paragraph, in 
favor of the view that no noticeable regular reflection of the rays takes 
place from any of the substances examined. Other experiments, which I 
here omit, lead to the same conclusion. 

a * # * # If we compare this fact with the observation already 
mentioned, that powders are as transparent as coherent masses, and with 
the further fact that bodies with rough surfaces behave like polished 
bodies with reference to the passage of the X-rays, as shown also in the 
last experiment, we are led to the conclusion already stated that regular 
reflection does not take place, but that bodies behave toward the X-rays 
as turbid media do toward light. 

11 Since, moreover, I could detect no evidence of refraction of these 
rays in passing from one medium to another, it would seem that X-rays 
move with the same velocity in all substances ; and, further, that this 
speed is the same in the medium which is present everywhere in space 
and in which the particles of matter are imbedded. These particles hin- 
der the propagation of the X-rays, the effect being greater, in general, 
the more dense the substance concerned. 

' ' Accordingly it might be possible that the arrangement of particles 
in the substance exercised an influence on its transparency j that, for in- 
stance, a piece of calcite might be transparent in different degrees for the 
same thickness, according as it is traversed in the direction of the axis, 
or at right angles to it. Experiments, however, on calcite and quartz 
gave a negative result. ' ' 

Sir G. G. Stokes, 1 "The Wild Lecture," lucidly says : " Everything 
tends to show that these rays are something which, like rays of light, 
are propagated in the ether. What, then, is the nature of this process 
going on in the ether? Some of the properties of the Rontgen rays 
are very surprising, and very unlike what we would be in the habit 
of considering with regard to rays of light. One of the most strik- 
ing things is the facility with which they go through bodies which are 
utterly opaque to light, such, for example, as black paper, board, and 
so forth. If that stood alone it would not, perhaps, constitute a very 
important difference between them and light. A red glass will stop 
green rays and let red rays through ; and just in the same way if the 
Rontgen rays were of the nature of the ordinary rays of light, it is 
possible that a substance, although opaque to light, might be transparent 

1 Ibid. 



THE EOXTGEN RAYS IX DIAGNOSIS. 149 

to them. So, as I say, that remarkable property, if it stood alone, 
would not necessarily constitute any great difference of nature between 
them and ordinary light. 

it * * * * B u t there are other properties which are far more 
difficult to reconcile with the idea that the Eoutgen rays are of the nature 
of light. There is the absence, or almost complete absence, of refraction 
and reflection. .Another remarkable property of these rays is the extreme 
sharpness of the shadows which they cast when the source of the rays is 
made sufficiently narrow. The shadows are far sharper than those pro- 
duced under similar circumstances by light, because in the case of light 
the shadows are enlarged as the effect of diffraction. This absence or 
almost complete absence of diffraction is, then, another circumstance 
distinguishing these rays from ordinary rays of light. In face of these 
remarkable differences, those who speculated with regard to the nature 
of the rays were naturally disposed to look in a direction in which there 
was some distinct difference from the process which we conceive to go on 
in the propagation and production of ordinary rays of light. Those who 
have speculated on the dynamical theory of double refraction have been 
led to imagine the possible existence in the ether of longitudinal vibra- 
tions, as well as those transversal vibrations which we know to constitute 
light. If we were to suppose that the Eoutgen rays are due to longi- 
tudinal vibrations, that would constitute such a very great difference of 
nature between them and the rays of light that a very great difference in 
properties might reasonably be expected. But assuming that the Eont- 
gen rays are a process which goes on in ether, are the vibrations belong- 
ing to them normal or transversal ? If we could obtain evidence of the 
polarization of those rays, that would prove that the vibrations were not 
normal but transversal. But if we fail to obtain evidence of polarization, 
that does not at once prove that the vibrations may not after all be trans- 
versal, because the properties of these rays are such as to lead us to 
expect great difficulties in the way of putting in evidence their polariza- 
tion, if, indeed, they are capable of polarization at all. Some experi- 
mentalists have attempted, by means of tourmalines, to obtain evidence 
of polarization, but the result in general has been negative. Of the two 
photographic markings that ought to be of unequal intensity on the sup- 
position of polarization, one could not say with certainty that one was 
darker than the other. Another way of obtaining polarized light is by 
reflection at the proper angle from glass or other substance ; but, unfor- 
tunately for the success of such a method, the Eontgen rays refuse to be 
regularly reflected, except to a very small extent indeed. The authors of 
the paper to which I have already referred appear to have had some 
success with the tourmaline. Like others who have worked at the same 
experiment, they took a tourmaline cut parallel to the axis and put on 



150 ELECTRO-THERAPEUTICS. 

top of it two others, also cut parallel to the axis, and of equal thickness, 
which were placed with their axis parallel and perpendicular respectively 
to that of the under tourmaline. 

"But they supplemented this method by a device which is not 
explained in the paper itself, although a memoir is referred to in which 
the explanation is to be found at least of those who can read the Russian 
language, which, unfortunately, I cannot. I can, therefore, only guess 
what the method was. It is something depending upon the superposition 
of sensitive photographic films. I suspect they had several photographic 
films superposed, took the photographs on these, and then took them 
asunder for development, and after development put them together again, 
as they had been originally. They consider that they have succeeded in 
obtaining evidence of a certain amount of polarization. If we assume 
that evidence undoubted, it decides the question at once. But as the 
experiment, as made in this way, is rather a delicate one, it is important 
for the evidence that we should consider well what we may call the 
Becquerel rays. I shall say merely that they appear to be intermediate 
in their properties between the Rontgen rays and rays of ordinary light. 
The Becquerel rays undoubtedly admit of polarization, and the evidence 
appears on the whole pretty conclusive that the Rontgen rays, like 
rays of ordinary light, are due to transversal, and not to longitudinal 
vibrations. 

' ' It remains to be explained, if we can explain it, wherein lies the 
difference between the nature of the Rontgen rays and the rays of ordinary 
light which accounts for the strange and remarkable difference in the 
properties of the two. I may mention that, although Cauchy and Neu- 
mann, and some others who have written on the dynamical theory of 
double refraction, have been led to the contemplation of normal vibrations, 
Green has put forward what seems to me a very strong argument against 
the existence of normal vibrations in the case of light. The argument 
Green used always weighed strongly with me against the supposition that 
the Rontgen rays were due to longitudinal vibrations ; and the experi- 
ments by which, as I conceive, the possibility of their polarization has 
now been established so completely in the same direction, showing that 
they are due, assuming them to be some process going on in the ether, to 
a transversal disturbance of some kind. ' ' 

Chemical and Photographic Effects. One of the peculiar properties 
possessed by the X-rays is that they produce a chemical action upon the 
haloids of silver, but have very little activity in other reactions. Dixou 1 
asserts that these rays affect no combination between CO and O 2 . AVith 
such combinations as argentic nitrate in alcohol or HgCl 2 in ammonium 
oxalate solution, the influence of the Rontgen rays is extremely feeble. 

1 Trans. Chem. Soc., 1896. 



THE RONTGEN RAYS IN DIAGNOSIS. 151 

The following law has been formulated by Vandevy ver. ' The action of 
the rays on a sensitive film varies inversely as the distance between them, 
instead of inversely as the square of the distance. 

Physiological Effects. The physiological action of the X-rays will be 
dealt with at length, in the chapter devoted to X-ray therapy. 

Theories. The nature and origin of the Rontgen rays is as little 
understood to-day as when first discovered. Many and varying theories 
have been propounded ; principal among these may be cited the views 
put forth by Rontgen, Crookes, J. J. Thomson, Stokes, etc. 

Below are tabulated the theories advanced by scientists regarding the 
probable nature of these rays. 2 



1. Solid particles. { Lera y- Tesla ' 
ISalviom, Att. d. 



Perug., 8, 1 and 2. 

2. Ether wind. 

3. Ether vortices. Michelson, Amer. J. Science, p. 312. 

4. Ether waves (actual movement) . 

5. Electro-magnetic. 

Longitudinal. Rontgen, 1895, foe. tit. 

Boltzmann, J. f. Gasb., 39, p. 71. 

With transverse component. Jaumann, Wied. Ann., 57, p. 147. 
Transverse, (a) Very small. Goldhammer. 
(b) Short trains. G. G. Stokes. 
J. J. Thomson. 

6. New phenomenon. 

Visibility of the Rontgen Rays. 

Prof. E. Dorn 3 asserts most positively that the X-rays are visible, 
opinions to the contrary notwithstanding. In support of his statement, 
he says that when the back of the anti-cathode is presented to the 
observer's eye, a faint fluorescence is visible on the screen, whereas, 
with the tube in the correct position, the eye accustomed to darkness 
could not detect the smallest action, although the appearance of light was 
distinctly seen, both before and later. In corroboration, Rontgen himself 
held an absorbing metal plate, containing a narrow slit, before the eye, 
when he observed a bright line, either straight or curved in direction, 
depending on the relative positions of the anode, the slit, and the eye. 

Velocity of Propagation of the X-rays. 

R. Blondlot 4 has studied the speed of propagation of X-rays, by the 
fact that a discharge passes more readily across a spark-gap when under 

1 Jour, de Phys., 1897. 
2 Hyndmanon "Radiation." 
8 Archives of the Rontgen Ray, May, 1898, p. 69. 

* Comptes-rendus, Oct. 27 and Nov. 3, 1902. The Electrician (translation), Nov. 
21, 1902. 



152 ELECTRO-THERAPEUTICS. 

the influence of the rays than when the latter are not present. He also 
demonstrated that the X-rays have a definite rate of speed, possessing a 
velocity comparable to the Hertzian waves. Believing that the rate of 
propagation of the latter through wire is equal to the velocity of light, 
Blondlot asserts that the velocity of X-rays, Hertzian waves, and 
ordinary light waves is equal. 

Velocity of the Rontgen Rays. 

E. Marx l has succeeded in measuring the velocity of the X-rays, by 
a method very similar to that of Fizeau's toothed wheels, as used for 
determining the velocity of light ; but in Marx' s method the intermit- 
tence is inherent in the source and the receiver themselves. Rontgen 
rays are generated by Hertzian waves, and, as the Rontgeu rays are the 
parent rays of the cathode rays, the latter are only emitted during the 
negative phase of the Hertzian oscillation, i. e. during the intermission. 
The receiver is an electrode, connected with the same exciting agent and 
producing secondary cathode rays, under the influence of the incident 
Rontgen rays, but only when found by them in the negative phase. 
Now, as the X-rays produce peculiar oscillations in the leads, Marx has 
overcome this difficulty by employing a method in which the source 
and receiver are both fed from the same Hertzian oscillating wires, 
minimizing infinitesimally the oscillations by shifting the bridge. 

Charging Action of the Rontgen Rays. 

That the X-rays are capable of charging bodies has been maintained 
by Righi but denied by others. Halm' s * views are fully in accord with 
those of Righi. The discord that exists is solely due to the masking 
action of the secondary rays. All bodies acted upon by the X-rays 
acquire a positive charge ; hard rays are most effective in charging, as is 
also a high atomic weight. 

1 Physikalische Zeitechrift, November 9, 1905. 

2 Annalen der Physik, No. 11, 1905. 



CHAPTER I 
THE RONTGEN RAY APPARATUS AND ITS MANIPULATION. 

I. The Induction Coil. 

A. LAWS OF FAKADAY, OK THE ELEMENTARY LAWS OF INDUCTION. 

THE induction or Ruhmkorff coil is an instrument for converting 
low voltage into high E. M. F., thus necessarily involving the principles 
of electro -magnetic induction. 

In 1831 Faraday discovered that currents may be induced in a closed 
circuit by moving magnets near it, or by moving the circuit across the 
magnetic field. Further investigation showed that a current whose 
strength is changing may induce a secondary current in a closed circuit 
near it. 

In 1832 Faraday observed that a similar induction of a secondary 
current occurred when interrupting an existing primary current, and the 
current produced in the secondary circuit on interruption travels in the 
same direction as the former. When closing the primary circuit, the 
secondary current travels in the opposite direction. By rapidly 
"making" (closing) and u breaking" (interrupting) the primary cir- 
cuit, there is produced an alternating current in the secondary circuit, 
which is constantly changing in direction. 

The current strength produced by induction in the secondary circuit 
is dependent upon the following principles : 

The greater the ratio in the induction coil between the primary sec- 
tion and the secondary coil, the greater will be the resulting E. M. F. of 
the induced current in the secondary circuit. 

By induction, the greater the E. M. F. in the primary circuit, the 
greater the increase of current strength in the secondary circuit. 

The strength of the induced current will vary with the rapidity 
with which the iron core is alternately magnetized and demagnetized. 

The working capacity of an induction coil depends upon the circum- 
stances that : 

The core must be of soft iron that can readily be magnetized or de- 
magnetized by an interrupter in the primary circuit. 

The secondary circuit must consist of a great many turns of fine 
wire, so as not to increase the bulk. 

The primary coils carry the current from battery, accumulator, or 
main, which magnetizes the core of soft iron, thus creating a powerful 
magnetic field around and through the secondary windings. The inter- 
rupter causes the current in the primary circuit to vary rapidly, and the 

153 



154 



ELECTRO-THERAPEUTICS. 



resulting variations in the intensity of the magnetic field react upon the 
secondary coil, inducing an electro-motive force in each and every turn of 
the wire. The " making" of the magnetic field is much more slowly 
accomplished than its destruction when the current is "broken," thus, 
the induced electro-motive force in the secondary at " breaking" is by 
far the greater. The induced secondary current when "making" is 
greatly below that when " breaking," so that the former is found insuffi- 
cient in exciting a vacuum tube. Advantage is gained from this phenom- 
enon because the induced current 
at "make" travels in the wrong 
direction and could not cause 
the tube to be excited, as it is 
in the case with the "break" 
induced current. 

The induction of currents 
in the secondary coil by means 
of the currents in the primary 
coil may be more readily under- 
stood from a consideration of 
Fig. 68. 

The battery "B" will cause 
a current to flow through the 
primary coil "P" when the cir- 
cuit is closed by the interrupter 
"I;" but the current does not 
instantly assume its maximum 
value. It takes an appreciable 
time to rise to the current value 
set by the resistance of the cir- 
cuit. This gradual rise of the 
current is due to the presence 
of the self induction of the cir- 
cuit, the largest percentage of which exists in the primary coil. During 
the time that this self-induction current is rising in the primary 
circuit, a magnetic field is being established about the primary wind 
ing. The strength of this magnetic field is at all times directly pro- 
portional to the primary current. It is, therefore, zero at the time that 
no current flows, and a maximum when the current has stopped rising. 
This magnetic field embraces the secondary coil as well as the primary. 
While the primary current is rising and the magnetic field is growing, a 
voltage is produced in the secondary coil by the expansive lines of mag- 
netic force, which voltage tends to produce a current in the secondary 
coil opposite in direction to that flowing in the primary. 




FIG. C8. Diagram illustrating the principles of in- 
duction. (After Donath. ) 



THE RONTGEN RAY APPARATUS. 155 

This current, induced at this time, is of low voltage and is not the 
current desired in the X-ray tube. It is the "inverse" discharge which 
tends to blacken the tubes and lower the vacuum at the time of the 
running of the tube. 

When the interrupter opens the primary circuit, the primary cur- 
rent suddenly stops, and at the same time the magnetic field collapses, 
inducing a very high voltage in the secondary coil. This tends to pro- 
duce a current in the secondary coil in the same direction as the current 
flowing in the primary. 

B. THE CONSTRUCTION OF THE INDUCTION COIL. 

1. The Primary Coil. The first requirement in the construction of 
an X-ray induction coil consists in arranging into a cylindrical bundle 
many equal lengths of finely annealed charcoal iron wire, and in winding 
around this core, several layers in thickness, a stout insulated (pri- 
mary) wire so arranged as to have terminals at one end for future con- 
nection. Surrounding this cylinder is another cylinder made of some 
specially selected substance, as ebonite, hard rubber, shellac, or resin, to 
afford insulation. 

2. The secondary coil is composed of a great number of windings of 
very fine wire, to effect the principle that a high E. M. F. is in a great 
degree dependent upon the number of turns in the secondary coil. The 
secondary coil is found on the market made up in sections. This allows 
of the easy replacement of any one section ; a source of economy. 

The ends of the secondary coil are connected with brass terminals 
mounted upon the flanges, an ebonite cover or separate stands. The 
whole finished coil is suitably supported upon a stage of wood with the 
other necessary appliances. 

3. Condenser. The purpose of the condenser is for the sudden and 
complete demagnetization of the soft iron core the length of the spark 
depending upon the abruptness with which the demagnetization is 
accomplished. Another use of the condenser is to prevent the sparking 
of the extra current passing between the contact studs of the interrupter. 
The more recent condensers are made in sections and are provided with 
an indicating dial, designating how much to increase or decrease the 
capacity of the condenser, as determined by the size of the primary coil. 
The condenser is made up of many sheets of tin-foil separated from 
each other by sheets of paraffin paper, or paper impregnated with resin 
or plates of mica. The foil is arranged thus : The first, third, and fifth 
sheets are so connected as to overlap the paper sheets on one side ; the 
same method is applied to the union of the even numbered sheets of the 
other ; these layers are connected with those parts of the interrupter 
where the u inake" and " break" occur. The unit of capacity is the 



156 ELECTRO-THERAPEUTICS. 

11 micro-farad." The capacity of condensers used in induction coils 
varies from one-half M. F. to 12 or 15 M. F., depending upon the size, 
make of the coil, and the voltage upon which its primary circuit is used. 
The commutator is an appliance mounted on the base for the support 
of the coil, and placed at the side of the interrupter. It is a double 
reversible switch capable of changing the direction of the current in the 
primary and consequently in the secondary circuit. 

C. INTEEEUPTEES. 

The interrupter (rheotome) is a device employed by electricians for 
the purpose of effecting rapidly succeeding induced currents in the 
secondary coil, by a corresponding rapidity in the opening ( u break- 
ing") and closing (" making") of the primary coil. Interrupters are 
divided into the mechanical and the electrolytic, with the following 

subdivisions : 

1. Mechanical. 

Platinum. 

Vibrating hammer. 
Independent. 
Self-starting. 
Vril. 
Mercury. 
Dipper. 
Rotary. 

Disk. 

Johnston. 

Jet. 

2. Electrolytic. 

Wehnelt. 

Caldwell and Simon. 

Platinum. The vibrating hammer which vibrates in response to the 
magnetism exerted by the primary coil is little used at present. 

The independent vibrating hammer is so constructed that a magnet 
placed in a shunt circuit can vibrate the hammer independently of the 
coil. The diameter of the contacts should be as large as possible, and 
the faces absolutely parallel, in order to carry all the current required. 
The number of interruptions in this hammer is dependent upon the 
number of weights attached to the vibrating hammer. The greater the 
number of weights employed, the fewer will be the resulting vibrations. 

The self -starting (Figs. 69, 70) mechanical interrupter requires little 
attention from the operator, as he is not called upon to effect the vibra- 
tions. This ingenious invention is the work of H. C. Snook and Edwin 
W. Kelly, of Philadelphia, who aptly say : ' 

a This interrupter is a form of platinum break which is actuated not 
by the magnetic field of the coil itself, but by an independent electro- 




Fis. 69. Self-starting interrupter. 




FIG. 70. Diagrammatic sectional view of the self-starting interrupter. 
(Rontgen Manufacturing Co.) 



THE BONTGEN EAY APPARATUS. 



157 



magnet (9), which is in series with a small spring (11) and a set of plati- 
num contacts of its own, and is shunted directly across the supply wires. 

" The magnetic circuit is so arranged that a very powerful pull is ex- 
erted on the armature at the instant of starting from rest. This provides 
the self-starting feature which has given to the interrupter its name. 
The break is quite efficient and gives very little trouble. 

"This has been accomplished by making the magnetic circuit with 
a minimum amount of reluctance, and providing a properly shaped arma- 
ture and pole piece. The magnetic circuit is completed from the arma- 
ture to the base of the magnet coil through the interrupter spring itself. 
By this arrangement the only air gap in the path of the magnetic lines of 
force is that between the pole piece and the armature itself, making the 
tractive force exerted on the armature a maximum for the magnetizing 
current employed. ' ' 

The l ' mil ' ' interrupter is an old type of the spring platinum vari- 
ety. It is rapidly passing into disuse, but it possesses the great advan- 
tage of being capable of generating a high E. M. F. in the secondary 
coil. Sparking is unavoidable, and its occurrence constantly menaces the 
integrity of the platinum stud. 

To obviate this difficulty the elasticity of the spring is no longer taken 
advantage of, but in its place a light piece of flat metal, balanced on its 
edge, is substituted for the movable contact. 




FIG. 71. Mercury interrupter. 

Mercury. Mercury interrupters are of two kinds the dipper and the 
rotary. In the dipper variety an electro-motor (Fig. 71) is employed to 
effect the "dip," and likewise the withdrawal of a platinum-tipped rod 
from contact with the mercury for the greater part of each cycle ; it is out 
of the mercury for a relatively short period, because the current is not 



158 ELECTRO-THERAPEUTICS. 

generated at the moment of contact. In this form of interrupter the sur- 
face of the mercury is covered with a layer of alcohol, water, or petroleum, 
in order to decrease the oxidation resulting from " sparking." This form 
of " break " is cumbersome, being mounted on a separate base. Instead 
of being worked by the core of the coil, this interrupter may be brought 
into action by employing a small motor. One precaution, however, with 
the latter method is necessary. If the breaks are not started prior to the 
turning on of the current into the coil, the coil may suffer serious dam- 
age by the heavy influx of current upon closing the circuit, should the 
dipper be immersed in the mercury. 

Davidson's Rotary Contact Breaker. Dr. Mackenzie Davidson's inter- 
rupter 1 (Fig. 72) consists of a vane mounted at the end of a spindle 
driven by a small motor. As the latter rotates, the vane makes and 
breaks contact with the mercury contained in a trough or box, on the 
cover of which the motor is mounted. The motor and spindle are placed 
at an angle of aboufc 30 so that the spindle passes down through a hole 
in the lid. The mercury is thus closed in, and splashing is prevented. 
The break is found to work well with electro-motive force up to 100 volts. 

The disk interrupter, a subdivision of the rotary, is included in that 
class of 1 1 breaks ' ' in which the contacts are separated by the revolutions 
of a disk effected through the agency of an electro-motor. The contacts 
and disks are immersed in alcohol or petroleum, to prevent the likelihood 
of sparking. 

The Johnston Mercury Interrupter. Dr. Geo. C. Johnston, of Pitts- 
burg, exhibited before the American Rontgen Ray Society in Baltimore, 
1905, a new form of mercury interrupter (Fig. 73) for which he claims 
special features. There is no oxidation of mercury, no sticking, uniform- 
ity of discharge, absolute control of speed and current, it will not ex- 
plode, it occupies little space, makes little noise, and will run for months 
with little attention. He describes the Johnston mercury interrupter as 
follows : ' l The interrupter consists of an inclined shaft at the lower end of 
which is a peculiar shaped blade, alternately dipping into a pool of mer- 
cury. This shaft is rotated by means of a motor to which a speed con- 
trol is attached. The containing case is of heavy cast iron, and the top is 
screwed down and insulated from the case with a thick rubber gasket and 
insulated bushings. One end of the box is inclined toward the mercury 
pool and arranged with grooves, so that when the mercury is thrown to 
the top of this incline by the action of the blade, in running back into the 
pool, it travels slowly over a considerable section of the cast iron and 
leaves any impurities that it might have contained in them. 

"The box is arranged to be air-tight, and the pet cock is fastened 
in the lid, by means of which the mercury or any other liquid can be 

Archives of the Rontgen Ray, Jan., 1901. 




FIG. 72. Davidson's interrupter. 




FIG. 73. Johnston's mercury interrupter. 



THE EONTGEN BAY APPARATUS. 



159 



poured into the interior. It has been found that when the proper amount 
of mercury is placed in the pool and a few drops of wood alcohol added, 
after the first slight explosion takes place, the interrupter will run along 
without any sparking, and consequent oxidation of the mercury, and 
break currents of considerable magnitude, as much as 40 or 50 amperes. 
The quality of the spark obtained from the secondary of an induction 
coil with this amount of current flowing through its primary, is surpris- 
ingly thick and heavy, and the discharge is of exactly the right quality 
to produce the results in radiography. When the alcohol explodes in 
the box, there is a slight pressure produced, which is retained, owing to 
the air-tight quality of the box, and the interrupter will run along indefi- 
nitely with absolutely no attention. If any irregularity of the secondary 
sparking is noticed, all that 
is necessary to do is to open 
iie pet cock, pour in an ounce 
3r so of mercury and a dozen 
or fifteen drops of wood alco- 
hol, close the pet cock, and 
the interrupter is ready for 
use again. This interrupter 
will run for a long time with- 
out interior cleaning, which 
can be readily accomplished 
without taking apart, by un- 
screwing a plug in the bottom 
of the box, letting the mer- 
cury drain out, and filling the 
box with water and giving it 
two or three vigorous shak- 
ings. After draining the 
water out, the plug is re- 
placed tightly, and some fresh 
mercury added, when it is ready for another three or four months' use." 

In the jet interrupter, a jet of mercury impinges upon a rotating 
metallic .surface. The jet carries the current, and the length of contact 
can be regulated according to the operator' s demands by elevating or low- 
ering the contact plate relatively to the jet. The break is instantaneous 
and complete. 

The electrolytic interrupters are subdivided as follows : Wehnelt and 
the Caldwell and Simon. 

This type of interrupter depends upon the formation of gas bubbles 
at the poles of an electrolytic cell. 

The electrolytic u break' 7 of Wehnelt (Fig. 74) 7 the most rapid of all 




FIG. 74. Wehnelt interrupter. 



160 



ELECTEO-THERAPEUTICS. 



interrupters, consists of a jar holding the electrolyte (dilute sulphuric 
acid s. g. 1016 to 1020), a plate of lead (the cathode), and a piece of 
platinum insulated except at its extremity (the anode). 1 

The greater the quantity of sulphuric acid employed, the greater the 
current and the better the conductor. A steady electro-motive force of at 
least 24 volts is applied to the interrupter, arranged in series with the 
primary circuit of the coil. Should the platinum not constitute the 
anode, the interruptions will not be sharp and regular. Under these con- 
ditions the platinum is very rapidly consumed. 

One of the advantages of this interrupter is that either a continuous 
or alternating current can be employed. It likewise obviates the use of 

the condenser, and in many 
instances the rheostat. An- 
other advantage is, that it 
allows tremendous amounts of 
amperage to pass to the pri- 
mary coil, averaging any- 
where from fifteen to forty 
amperes. 

The number of interrup- 
tions in this break varies from 
1000 to 40,000 per minute, 
and is dependent upon the 
size of the exposed portion of 
the platinum point. This can 
be regulated by presenting a 
^ larger surface either by means 

f , m ; of a screwing device, or by 

; ; j several thicknesses of these 
points in the same electrolyte. 
The rate of interruption can 
be gauged by the tuning- 
fork ; or as the result of ex- 
perience, the operator recognizing a peculiar humming, musical note. 
A recent device, added to this instrument, is a spiral leaden tube, 
which acts as the cathode, and as the sulphuric acid (electrolyte) becomes 
warm the interruptions cease to be regular, and water from a faucet is 
passed through the tubing in order to cool the electrolyte. 

In the film variety of the Wehnelt interrupter, the interruptions are 
brought about by the production of a non-conducting film of vaporor gas 
around the anode. The effects produced are, in a measure, proportionate 




FIG. 75. Simon Interrupter. 



1 In 1899 Wehnelt, of Charlottenburg, first applied the above principles to the 
satisfactory working of the X-ray coil. 



THE RONTGEN BAY APPARATUS. 



161 



to the thickness of the wire, so that the employment of three or more wires 
of different gauges is often expedient. Most advantage is gained with an 
E. M. F. of 50 to 120 volts. The voltage is regulated by means of a rheo- 
stat. For short runs a voltage of 40 to 100 volts is all that is required, 
but its employment must be for a brief interval only. To continue for a 
half hour or an hour would cause the generation of great heat in the acid, 




FIG. 76. Fricdlander electrolytic interrupter. The electrolyte is composed of a 10 per cent, solu- 
tion of magnesium sulphate, and the anode is made of German-silver wire. The operator can control 
the current for the work in hand by simply turning the thumb-screw. It operates by either the direct 
or alternating currents. 

with a stoppage of the mechanism. To avoid this drawback, many devices 
have been employed. Among the most important are the use of the sul- 
phates of magnesia and potash-alum in place of the acidulated solution, 
and also by making the container larger, and through it maintaining a flow 
of cold water. This type of interrupter is easily managed; its most pro- 
nounced disadvantage is its constant humming sound, while its very high 
E. M. F. has a tendency to disturb the vacuum of the Crookes tube. 
11 



162 ELECTRO-THEKAPEUTIC&. 

There are very many varieties of the electrolytic interrupter, 
numerous modifications of the Wehnelt, bearing various names. 

Caldwelland Simon. In 1899 Mr. E. W. Caldwell, of New York, and 
Dr. H. T. Simon, of Berlin, simultaneously and independently of each 
other, had published the description of a new type of electrolytic inter- 
rupter, the principle involved being the production of interruptions by 
the vaporization of the electrolyte at the aperture connecting the two 
chambers. The apparatus consists of a glass jar containing dilute sulphu- 
ric acid, with two plates of lead, one for the anode and the other for the 
cathode. A partition of glass or porcelain, containing a hole, separates 
these two plates and at the same time allows the communication of 
the liquids in the two portions of the cell. The frequency of the inter- 
ruptions is dependent upon the strength of the current, the size of the 
aperture, the resistance offered by the electrolyte, and to some extent 
upon the inductance of the circuit. A pointed rod, non-conducting in 
nature, regulates the number of interruptions by increasing or decreas- 
ing the calibre of the aperture. The electrolytic action results in the 
generation of bubbles of gas (steam), which break the circuit ; these 
bubbles are almost instantaneously dissipated and then renewed, their 
frequency being somewhat dependent upon the size of the aperture. 
More recently the septum between the two containers has been made of 
perforated porcelain disks, in order to prevent the damage incident to 
the inner tube, from the unequal expansion of the glass of which it was 
formerly made. 

Dr. Simon claims that the advantage of his interrupter (Fig. 75) 
over the Wehnelt is to be found in its being independent of the current 
direction, working equally as well with the alternating as with the contin- 
uous current ; because in the Caldwell-Simon interrupter, the watery 
vapor is periodically evolved and followed each time by condensation, 
and thus the current is alternately made and broken. 

A useful electrolytic interrupter is shown in Fig. 76. 

D. VARIETIES OF INDUCTION COIL.. 

(a) Variable Primary Induction Coils. Walter, of Hamburg, con 
structed induction coils with a variable number of sections for the pri- 
mary, in order to obtain the proper quality in the secondary discharge. 
This he effected by arranging the windings of the primary coil in a num- 
ber of sections, and passing the current through a greater or lesser number 
of these divisions as he required more or less current. Each of the coil 
windings can be connected in series, in two groups, or iu parallel. These 
windings end in wires to form contacts at one side of the primary coil. 
Upon these contacts are placed pins which support plugs, and so arranged 
as to effect the desired connection between the terminals of the coil 



THE RONTGEN KAY APPARATUS. 163 

endings. By connecting the windings in series (for soft tubes), the self 
induction of the primary coil is much augmented. By connecting in 
parallel (for hard tubes), or in two groups (for tubes of medium density), 
self induction is materially decreased. 

The primary coil is covered with an insulator of glass, ebonite, par- 
affin, etc. This coil is frequently manufactured in a varying number 
of sections or divisions, so that it can be replaced at pleasure within 
the secondary coil, and be renewed, at any time, thus obviating the 
unnecessary expense of providing for the cost of the entire coil. 

The secondary circuit must be perfectly insulated ; lack of this most 
important provision will result in discharges within the apparatus, fusing 
the wire and destroying the coil. The insulating material used may be 
paraffin, varnish, wax, or silk. Whatever substance be used, the several 
layers of wires which are already of themselves well insulated must be 
likewise insulated from one another. 

A wise expedient in this connection has been the device of employ- 
ing several short secondary coils in place of a single secondary coil. This 
artifice insures better insulation, easy repair in the event of short- 
circuiting, and the lessened cost incident to replacement. 

The Jumbo Coil. This coil, owing to its mechanical arrangement, does 
not throw more than a 9-inch spark (23 cm. ), thus making it necessary to 
insulate only for the voltage equivalent for that spark length. This saves 
much valuable space, and it is therefore possible to use more iron in the 
primary core, as well as heavier wire on both primary and secondary, 
which are also brought into closer proximity to each other. In this way 
the efficiency is so increased that when running on 110 volts direct current, 
it will push 50 per cent, more energy through a tube backing up three 
to four inches parallel spark-gap than any standard 20-inch (50-cm. ) 
coil. (See Fig. 101.) 

By means of the variable inductance of the primary, the value of 
which is changed by moving a switch, it is easy to adjust the voltage 
delivered by the coil to suit the resistance of the tube being used, so as to 
force the greatest amount of X-ray producing energy through it. 

The switch -board is provided with a voltmeter and ammeter, a 
switch for making connection for use of either the mechanical or electro- 
lytic interrupter, a condenser-switch used in connection with the mechan- 
ical interrupter, a reversing-switch to change the polarity of the dis- 
charge, and a regulating rheostat. 

The usual method of operation is to connect the tube to the coil, set 
the inductance switch at point number 6, maximum inductance, connect 
the interrupter desired, close the reversing-switch so as to allow the 
current to pass into the primary, and adjust the current by means of the 
regulating rheostat. 



164 



ELECTRO-THERAPEUTICS. 



If the tube does not light up properly, the current is thrown off, the 
inductance switch changed, and the tube excited again. This adjustment 
is very simple, and the proper inductance for any tube for skiagraphy or 
for X-ray therapy is readily obtained. 

(b) Tesla Coil. The Tesla coil became universally known when 
Rontgen's discovery was first verified throughout the civilized world. 
The alternating currents resulting from the action of this device are of 
exceedingly high frequency (10 to 20 millions per second) as compared 
with the Ruhmkorff coil with mechanical contact breakers ; whilst the 
induced secondary electro-motive force of the Tesla coil is hundreds of 
thousands of volts. Comparable to the rapidity of oscillations thus pro- 
duced, is the discharge of a condenser or Ley den jar. These discharge 



V 





FIG. 77. The Tesla oscillator. 



FIG. 78. Outer view of the same. 



currents are made to pass through the primary of an induction coil, devoid 
of the usual iron core. The primary is made up of a very few turns of 
thick wire ; the secondary has comparatively only a few turns of wire. 

So great is the electro-motive force that the average non-conductor 
would fail to effect insulation ; hence the necessity of immersing the whole 
coil in an oil bath from which only the primary and secondary wires 
protrude. 

For charging the condenser, it becomes necessary to pass the alter- 
nating current through a transformer, which raises its pressure to about 
6000 volts. The existence of a bright, snappy spark, in the adjustable 
spark-gap, indicates the discharge of the condenser. 

The employment of the Ley den jar is fraught with much danger, if 
care is not taken to make the primary circuit inaccessible. On the other 
hand, sparks taken from the secondary of a Tesla coil are innocuous; but 
the intense and continuous crackling produced by the primary spark-gap 
is frequently terrifying to nervous patients and children. 

Tesla Oscillator. (Figs. 77, 78.) This device consists of three parts : 
A vertical electro- magnet, well wound very many times with stout wire, 



THE EONTGEN RAY APPARATUS. 165 

possessing much self-induction. A condenser, which is charged by the 
self-induction of the electro-magnet on breaking the circuit which dis- 
charges into the primary of the horizontal transformer. The latter is 
composed of a single turn of copper ribbon, about six inches wide, and 
its secondary consists of one layer of thick wire. 

The working of the oscillator is as follows : The current from the 
terminal, T 2 , magnetizes the electro-magnet, M, which, in attracting its 
armature, breaks the circuit at B, and the high electro-motive force, due 
to the magnet's self-induction, charges the condenser C. The discharge 
being extremely rapid and oscillatory and flowing through the primary, 
P, has its voltage increased in the secondary, S. The rate of vibration 
should be tuned below one hundred per second. The oscillator is, for 
some unknown reason, not put upon the market. In the laboratory it is 
found to be inexpensive, compact, and very durable ; the absence of any 
delicate wire and the general construction of the device afford almost 
indefinite immunity against any disturbance of its insulation ; but for 
skiagraphic work, special tubes are demanded, because of the alternating 
current generated by the oscillator. 

(c) Kinraide Coil. The Kinraide coil, the ingenious invention of 
Mr. T. B. Kinraide, of Boston, is a special modification of the Tesla coil 
and possesses many features of merit. 1 Among other things Mr. Kin- 
raide remarks : ' ' The coil I have succeeded in making was the result of 
the repeated breaking down of the Ruhmkorff coils, ranging from six 
to eighteen or twenty inches. I have succeeded very well in removing 
from the apparatus the danger of destruction so common to the ordinary 
Ruhmkorff coils, etc. My object was to remove the high-potential 
region of the coil as far as possible from the primary. In my coil this 
has been done, the low potential region of the single coil being the only 
part it could come in contact with * * * * the moment the current 
is broken, the lines of force collapse and fall inward in the direction of 
the arrows. (Fig. 79.) In this way the highest potential is produced 
in the outer terminal of a thin flat spiral secondary, if located in the 
plane of the arrows, and the low potential at the centre. By that method 
of winding, as the turns grow longer, the resistance per turn increases, 
and the tendency of the discharge to pass from one turn to the other in- 
creases. If a suitable primary were placed on the outside of this second- 
ary, the reverse would be the case, and hence the tendency to break down 
would be entirely removed in the section of the secondary. In my coil 
this is the arrangement adopted, and the lines of force fall away from the 
centre towards the primary in the direction of the arrows in Fig. 80, pro- 
ducing a very high potential at the centre, and practically very little or 

1 American Electro-Therapeutic Association, held at Buffalo, New York, Septem- 
ber 24-26, 1901. 



166 



ELECTEO-THEKAPEUTICS. 



no potential at the outer turns, so that the centre discharges in the 
proportion of about six inches towards the earth wire whilst the outer 
terminal discharges about three-fourths of an inch only. To remove all 
tendency of discharge towards the primary, two of these coils were placed 

*. 




FIG. 79. Lilies of force fall in the arrows in the older form of coil. 

side by side (see Fig. 81). The two primaries are so arranged that a 
high-potential positive and negative is obtained from the centre terminals 
of the secondaries. There is practically no tendency whatever in this 
form of coil to break down." 




FIG. 80. Shows the arrangement by which the lines of force fall away from the 
centre towards the primary, as indicated by the arrows. 

In order to present in a clear and terse manner the peculiarities and 
advantages possessed by this recent invention, it is thought wise to 
append the following abridged description. 

The coil consists of two separate secondaries with their primaries 
connected in series. Each secondary has a high- and low-potential 



THE KONTGEN KAY APPARATUS. 



167 



terminal, due to the position and the method of winding the primary. 
The primary is located outside the secondary winding. The secondaries 
are wound in single flat disks and lie in the same plane as the primaries; 
with this method of construction the discharge from the two terminals is 
vastly different. The potential at the central terminal of the secondary 
is extremely high, while that of the outer turns near the primary is very 
low. By connecting the outer terminals of two such secondaries in series, 
the potential of the outer turns entirely disappears, hence there is no 
tendency to discharge into the primary. 

There is absolutely no heating in the primary of the Kinraide coil, 
as is the case with the Ruhmkorff, so that the insulation cannot be 
melted, nor is there heat generated where it can in any way affect this 
delicate part of the apparatus. 

A valuable feature is the water-cooled spark-gap. The heat ordina- 
rily developed in various parts of other coils is localized here, where it 
can be cared for without trouble or risk. In other coils there is a single 




FIG. 81. Shows the arrangement of two coils side by side : A, A, secondary ; B, B, primary. 

discharge from every interruption of the primary circuit. With this 
spark-gap we have a high-frequency apparatus giving many hundred dis- 
charges, or surgings, in the secondary for every break or reversal in 
the primary. This diminishes the time of exposure and increases the 
steadiness of the illumination of the screen. 

The interrupter is solid and durable, and with the spark-gap 
embodies an entirely new principle, running at constant speed till the 
motor is stopped. The alternating coil requires no interrupter, but the 
spark-gap is essential. The use of so little wire in the coil makes the 
apparatus compact, strong, and portable. The current consumed is about 
two hundred watts. It may be attached to any incandescent lamp socket, 
either direct or alternating current. 



168 ELECTRO-THERAPEUTICS. 

(d) Transformer with Closed Magnetic Circuit, for X-rays and High- 
Frequency Currents. Belot, iu his admirable work on Radiotherapy, thus 
describes the above apparatus by Gaiffe & Co. , of Paris : 

"This new apparatus makes it possible to utilize au ordinary alter- 
nating current, without an interrupter, either for the production of 
X-rays or for high-frequency currents. It consists of an ordinary trans- 
former, with a closed magnetic circuit, receiving an alternating current 
of 110 volts, which it converts into one of 60,000 volts. 

"The current should pass in one direction only. As the alternating 
current produced by this transformer changes its polarity with each 
oscillation, one series of waves must be absorbed before reaching the 
tube. For this purpose two Villard valves are inserted in parallel with 
the tube in a manner indicated by Villard himself. 

"A commutator converts the continuous into an alternating current. 
This installation is equally adapted for high-frequency work. It is only 
necessary to remove the Villard valves and insert the spark-gap in order 
to adjust it for this purpose." 

I have seen Drs. B6clere in the St. Autoine and Chas. Infroit in the 
Salpetriere Hospitals employing this apparatus with satisfactory results. 

(e) Coil icithout Interrupter. Max Levy read a paper before the 
Rontgeu Congress in Berlin on a new form of apparatus in which a high- 
tension alternating current is utilized without the interposition of any 
interrupter or condenser. The current is made unidirectional by means 
of a "strom-spalter," or current-sifter, i. e., a pair of spark-gaps, by 
means of which one phase of the alternating current is conducted to the 
earth while the other is used for driving the focus-tube. The author 
expressed the opinion that within the next few years we shall see the 
total abolition of interrupters for high-tension currents. I have seen 
the Crookes tube well lighted up in his laboratory in Berlin. 

Transformers. Koch and Sterzel, of Dresden, exhibited before the 
Berlin Routgen Congress, a transformer, by means of which a constant 
current is transformed into au alternating current through the agency of 
a dynamo, which drives the secondary current-rectifier on the same 
spindle, thus insuring synchronism. A step-up transformer with closed 
magnetic circuit is used. 

The Grisson Resonator. 1 This is a device for dispensing with the use 
of an interrupter, and thus doing away with the " make " current, which 
is so destructive to the focus-tubes. A condenser of large capacity is 
fitted with a commutator, and so arranged -that it is charged alternately 
to a positive and negative potential. This is connected to the primary 
of an induction coil, whose self-induction is so adjusted to the capacity of 
the condenser that resonance is obtained. When this is connected to a 

1 Archives of the Rontgen Ray, April, 1906, p. 308. 



THE RONTGEX RAY APPARATUS. 169 

source of constant current, unidirectional impulses pass through the pri- 
mary, and these are transformed in the secondary to the necessary tension 
required for working the focus- tube. 

Since at the end of each discharge the potential of the condenser falls 
to zero, there will be no spark when the commutator is reversed. We 
are therefore able to use a simple mechanical commutator, consisting of 
a massive copper collector, with two rotating rings connecting its plates. 
The current is conducted to these rings by means of contact brushes. 
This commutator is rapidly rotated by an electro-motor. The primary of 
the induction coil is introduced between the electric source and this com- 
mutator. When the circuit is first closed there is a sudden rusli of elec- 
tricity through the coil, the current instantaneously attaining a maximum 
value. As the condenser becomes charged, the intensity of the current 
gradually decreases to zero. When this has occurred the commutator 
will break the circuit without any sparking (since there is no current). 
As the commutator makes contact again with the opposite plate of the 
condenser, there will be another sudden rise to the maximum current, 
followed by a gradual fall to zero, as this plate now becomes charged to 
the potential of the source. The contact is again broken after the cur- 
rent has fallen to zero. The primary of the induction coil is thus trav- 
ersed by a series of undirectional impulses, each of which rapidly attains 
a maximum value, and- then very gradually falls to zero the ideal form 
of current for obtaining a practically unidirectional current in the sec- 
ondary. A point of interest is that it is the "make" current which is 
utilized in this apparatus, whilst the l ' break ' ' is suppressed ; whereas 
in the ordinary coil our efforts have been directed to suppressing the 
' ' make, ' ' and utilizing the l i break ' ' current. 

Scheidel- Western Coil. 

Recently there has come into the market the above-named machine, 
which has merited much approval. It is described as follows : 

"Until recently it had been considered a physical impossibility to 
pass more than 8 or 10 milliamperes through an X-ray tube with an in- 
duction coil, and it even was supposed necessary to make exposures for 
hip-joints as long as three minutes, and even five. Improvements, how- 
ever, in the construction of this type of apparatus have demonstrated that 
30 milliamperes can be passed successfully through a tube and that hip- 
joints of various patients weighing 150 to 160 pounds can be radiographed 
showing perfect detail in one or two seconds and the thorax in a half-second. 

"The apparatus which is doing this work successfully was designed 
by Mr. S. Hutton of Chicago. (Fig. 81A.) 

' ' This machine differs from the older types of induction coils in the 
manner of changing the ratio between the primary and secondary, the 
manner of winding the primary, and the size of the primary core, as well 



170 ELECTKO-THEKAPEUTICS. 

as the material used in the manner of interrupting the current in the 
primary circuit. 

11 The sixteen inch (40 cm. ) primary core for accomplishing the above 
results weighs about 70 pounds, which is three times the weight of older 
type machines of an equal rating ; the winding is placed over the coil in 
four distinct layers, it having been found that a sectional arrangement 
from each layer increased the inverse current very materially. 

"The eight ends from the four primary windings are connected di- 
rectly with the Hutton inductance switch, which consists of drum seg- 
ments on the surface of which are arranged segments in such position that 
when rotated the latter will connect with brushes bearing on the drum and 
bring the layers or windings into service consecutively, according to the 
voltage required to light the tube of given vacuum. This arrangement 
permits of eight distinct changes of secondary voltage ranging frem full 
rated capacity of the instrument to one-fourth of the full rating without 
appreciably diminishing the current flow from the secondary. The switch 
is arranged with an indicator and dial, the dial being marked in the 
several valuations. 

" Owing to the increased number of magnetic lines due to the size of 
the core, a fewer number of turns of wire on the secondary spools will 
be required, consequently the internal resistance of the secondary, for the 
same voltage, is less with a consequent increase in current output. 

" A special insulating medium is used between the secondary and 
primary so that these two factors can be brought closer together without 
danger of puncturing ; this is accomplished by using a very high insul- 
ating medium, having a very low electro-static effect. l 

11 This coil has novel features worthy of note. The manner of connect- 
ing the milliameter by placing it on the switch-board alongside the am- 
meter ; the connections for the milliameter being taken from the centre of 
the secondary winding or neutral point, the hand can be placed on this 
meter when a tube is running full capacity, and no sensation is noted. 

" A third and adjustable terminal is arranged for connecting with 
the vacuum-regulator on a tube. This arrangement allows of the tube 
being regulated at the coil and not in proximity to the patient. These 
coils are operated with both electrolytic and mercury interrupters, the 
latter for treatment and the electrolytic for radiographic work. 

"The electrolytic interrupter with the 'special' has three platinum 
point electrodes and occasionally five j for the fast work these points are 
used in parallel ; this connection permitting of a more perfect interrup- 
tion of large currents at a faster rate, sixty and seventy-five amperes can 
be handled with ease in this manner, and when breaking or interrupting 
this current twenty-five to thirty milliamperes can be passed through a 
tube permitting exposures as short as one-half to two seconds." 

'The coils are generally assembled in a type known as "Combination," which 
means that in addition to the " Radiographic Special " a resonator is united with it for 
High-Frequency Treatments. 





FIG. 81A. Scheidel- Western coil combination radiographic special and high-frequency 
outfit for alternating or direct current. 



Hi Rectifier. 




AA/WWWW 
o r 10 if 

fffieostot 



Potential Switch **\ 



Secondary. 



FIG. 81B. Diagrammatic view of the Snook Rontgen Apparatus. 




FIG 81 C. The Snook Rontgen Transformer. 



THE EOXTGEX EAY APPAEATUS. 171 

Personally, I have taken with this coil, a Bontgeuogram of the hip of 
a patient weighing 150 pounds, at a distance of 20 inches (50 cm.) with 
a current of 30 ma. on a Lumiere plate, exposure two seconds, high 
vacuum tube 4-iuch (10 cm.) spark. The plate was later developed 
with edinol solution, and gave satisfactory results. 

The Snook Rbntgen Apparatus. 

11 This is a new type of X-ray machine, that obviates the employment 
of an* interrupter. l It is entirely free from inverse discharge and can 
deliver more energy to a Crookes tube than the largest sized induction 
coil. Unlike the latter, its spark-length is estimated according to the 
kilowatt output ; it has, therefore, an energy rating an important factor 
in the accurate and scientific construction of apparatus. 

"This is the first X-ray machine to be given an energy-rating in- 
stead of a spark-length rating. 

"The plan of the apparatus is illustrated in the schematic diagram 
(Fig. 81 B), which shows that the alternating current is rectified by 
means of a high-tension rectifying or pole-changing switch. 

"The apparatus, when operated on a direct current, transforms the 
energy of the direct current into an alternating current of low tension by 
means of an inverted rotary converter, a special form of motor generator. 

"This low-tension alternating current is fed to a high-tension step-up 
transformer, the primary of which has an adjustable winding, in whose 
circuit is introduced an adjustable, non-inductive resistance, which regu- 
lates the amount of energy fed to the transformer. 

"This transformer differs from those previously used in that it has 
an extremely small amount of magnetic leakage and is designed for very 
high potentials. Its maximum potential is about 135,000 volte, the ad- 
justable resistance and ratio switch provide for a minimum of 10,000 volts. 

"The high-tension rectifying switch is mechanically connected to the 
shaft of the armature of the inverted rotary, in order to maintain absolute 
synchronism between the mechanical cycles of the rectifying switch and the 
electrical cycles of the high-tension circuit of the step-up transformer. 

"The most powerful induction coil will deliver only a few hundred 
watts of electrical energy to the X-ray tube, while this new apparatus 
has been constructed for as much as four kilowatts of energy output. 
This enormous energy makes it possible to radiograph, satisfactorily, all 
parts of the body in one second of time or less. 

"The direct current apparatus is illustrated in Fig. 81 C, where the 
inverted rotary may be seen at one end of the cabinet, within which is 
mounted the high-tension rectifying switch. Beneath the high-tension 
switch is the step-up transformer. A switch table, connected by flexible 
cables to the machine, contains the motor starter and control switches. 

1 The above article is from the pen of Mr. H. C. Snook, of Philadelphia, to whose 
ingenuity the invention of this device is due. 



172 ELECTEO-THEEAPEUTICS. 

"This machine is readily adapted to alternating current work, and 
when thus employed, instead of using an inverted rotary converter ad- 
vantage is taken of a self-excited single-phase alternator, which generates 
the low tension alternating current that is fed to the high-tension trans- 
former. This self-excited alternator is mechanically driven by an in- 
duction motor, which is chosen to suit the particular kind of alternating 
current supply that is used as a source of power. 

* ' Even when adapted to the alternating current, this apparatus does 
not deliver any inverse discharge and is more powerful than the largest 
sized induction coils, even when operated with electrolytic interrupters. 

"The development of this machine marks an epoch in Eontgen 
techuic. The recognition and interpretation of structural details in 
radiographs of the thoracic and the abdominal organs, as well as the 
rapidity of exposure are some of the advantages gained in the use of 
the above apparatus, not to mention its ease of manipulation and its 
lessened destructibility to focus tubes as compared with the induction coil." 

X-ray Apparatus Without an Interrupter. 

Since the inverse current causes instability and early deterioration 
of focus tubes, besides depreciating the quality of the picture, the Kny- 
Scheerer Company, in January, 1909, brought upon the market an X-ray 
apparatus to prevent or suppress this current. 

When connected with a direct-current supply, a direct-current 
motor with two collecting rings is used to convert the direct into an 
alternating current (Fig. 81F). The alternating current thus obtained 
is transformed in a stationary transformer into one of high tension and 
then commutated by a mechanical device, coupled directly with the axis 
of the motor-converter, into a pulsatory direct current. 

The commutation takes place in the following manner : 

" On the assumption that the positive pole of the current impulse at 
a given moment is at a, the high-tension current proceeds from there to 
the spark-stand b through the metal strip s of the insulation disk, to spark- 
stand c, to the anode d of the X-ray tube, leaves the latter at e, proceeds 
to spark-stand /, through the metal strip s' to the second disk of the 
spark -stand g, and further on to the negative pole of the transformer. 
Should the direction of the current change, the disks having simultane- 
ously rotated by 180, and the metal strips now being opposite the 
spark-stands g' and &', the current passes from h (now the positive pole) 
to g'j through the metal strip s' to c, through the tube d to/, through s to 
6, and back to a. The current, therefore, always passes through the 
tube in the same direction. 

"As illustrated by the diagram (Fig. SID), for a time there is no 
current, until with the increasing tension, the current breaks through the 



THE EONTGEN EAY APPARATUS. 



173 



tube. For a moment there is, of course, a considerable drop, the current 
diminishes and maintains itself for a time at practically a uniform height, 
and becomes zero at the moment when the metal strips on the insulation 
disks have passed the conductors. 

"The wave form thus obtained is incomparably more favorable than 
the abruptly falling curve of the opening current of an induction coil as 
illustrated in Fig. 81E. 




FIG. 81D. Diagram of the current in a tube supplied by an X-ray apparatus without interrupter. 

"To regulate the tension and intensity of the current, a selector 
switch is provided, by means of which more or less turns of the primary 
of the transformer can be intersected, thereby varying the ratio of trans- 
mission and consequently the secondary tension. The higher the vacuum 
of the tube, the higher is the penetrating power of the rays, and the higher 
also is the tension required to force the passage of a certain amount of 



tcunalary Current 
'upon clonnf Hit circuit 




Ttmt 



FIG. 81E. Diagram of the current in a tube supplied by an induction coil. 

current, owing to the proportional increase in the resistance. To regulate 
the current intensity a rheostat is provided in the primary circuit of the 
motor converter U. When the energy is taken from a direct-current 
source, the number of cycles and the primary tension of the alternating 
current may be controlled by placing another rheostat in series with the 
primary coil of the transformer. 



174 



ELECTRO-THERAPEUTICS. 



11 The method of regulation is very simple and requires the manipula- 
tion of two levers only. One of these adjusts the tension to the vacuum 
of the tube while the other controls the current intensity. The hemispheri- 
cal light zone is very distinct, showing that no inverse current is passing." 




FIG. 81F. Diagrammatic view of X-ray apparatus without an interrupter, for converting the direct 

into an alternating current. 

ioo- Plate Static Machine. 

This machine, devised by Dr. E. V. Wagner, of Chicago, is a 100- 
plate machine composed of 50 stationary glass plates (31 inches in 
diameter) and 50 revolving mica plates (28 inches in diameter). These 
are driven by a 5-h.p. motor connected vertically through the upper 
end of the axle, which is vertical. The cabinet is hexagonal and is 
topped with a crown. It is claimed that this machine is capable of 
giving anywhere from 1800 to 6000 revolutions per minute. 

Dr. Henry Hulst, of Grand Rapids, Michigan, who is using this 
machine, has kindly furnished me the following data : 

"The axle is vertical and the plates horizontal instead of vice ivrw. 
The motor is a 5-horsepower, 110- volt, capable of giving 1800 revolutions 
per minute, placed on top and connected with a pin coupling to the shaft. 
The end-thrust bearing consists of two ball-bearing disks running in 
oil. There are fifty 28-inch revolving plates. The case is very solidly 
made and is hexagonal ; consequently the machine occupies less floor space 




FIG. 81G. 100-plate static machine of Wagner. 



THE ROXTGEN RAY APPARATUS. 175 

than any ordinary machine. The vertical position of the revolving 
system is a great mechanical advantage. The discharge from point to 
disk gives a spark np to 16 inches (40 cm. ) and is a shower of exceed- 
ingly noisy sparks. From disk to point the discharge appears totally 
different; it is entirely noiseless and exhibits a thick yellow flame. The 
form of the discharge always designates its polarity. 

"With a Walter 6 tube in series, the full current registers about 
10 ma. in a Snook's meter. With this relatively small current it is 
possible to take a skiagram of a stomach in one second of time without 
the use of screens, although I generally choose a lower tube with a five- 
minute exposure. A two-second exposure of a renal calculus showed 
better than one taken in a woman weighing 170 pounds in 5 seconds. I 
have accomplished telerontgenography of the heart with the tube 10 feet 
from the plate and two intensifying screens in one second of time. For 
pulmonary skiagrams I use no screens, exposing up to one second of time 
according to condition of the patient. In other words, I can do faster 
work with 10 ma. disk-current from my machine than with 30 ma. from 
my 32 -inch coil. Moreover, such a coil current (as registered by the 
same Snook meter) used for one second, spots the target and for a period 
of two seconds will burn a hole in it." (Fig. 81G.) 

Dr. Hulst asserts that with this machine he can take skiagrams of 
the heart and kidney during a period varying from a fraction of a second 
up to two seconds; but a coil with the same amount of current would 
not answer the purpose. It is an accepted fact that the static machine 
produces an unidirectional current, and therefore has no injurious effect 
on the tube; besides, it is capable of generating a greater quantity of 
rays; whilst in the current produced by the coil there is always a reverse 
current, which is detrimental to the life of the tube. 

II. Electrical Discharges in Partial Vacua and the Crookes 
Vacuum Tube. 

Before taking up a consideration of the Crookes vacuum tube, it is 
well to observe that in a low- vacuum tube (Fig. 82) there is a column of 
luminescence at the positive pole and extending toward the cathode 
which is separated by a dark space (an interval in the illustration) desig- 
nated the dark space of Faraday. In Fig. 83 the magnet, AB, shows 
the deflection of the rays. As the pressure decreases, the luminosity in- 
creases in volume, and as the pressure becomes still smaller, the lumin- 
osity entirely disappears ; on the other hand, as the vacuum increases, 
there is a marked production of the cathode rays as shown in Fig. 84. 
The deflection of the cathode rays is represented in Fig. 85. In Fig. 86, 
the employment of one concave cathode in the presence of a number of 
anodes is shown. As the vacuum is gradually increased, the base of the 
cathodic cone becomes successive^ narrower as depicted in 2 and 3. 



176 



ELECTEO-THERAPEUTICS. 






B 




FIGS. 82, 83. Discharge passing through low-vacuum tubes. (Bouchard. ) 







FIG. 84. Cathode rays. The upper row are concave cathodes ; the lower rows are flat. Viewing 
from left to right, is shown the progressive increase in the production of the cathode rays as the 
pressure is gradually decreased. (Bouchard.) 




FIG. 85. Deflection of the cathode rays. (Bouchard . ) 



THE EONTGEN RAY APPARATUS. 



177 



The rectilinear propagation of the cathode rays is represented in 
Fig. 87, where the cathode C throws the shadow of the mica cross A 
on the wall of the tube A'. Around the shadow A' the tube shows a 
pronounced phosphorescence. 



A" 




f^^^^^^^ ' 




FIG. 86. Illustrating the effect of one cathode and several anodes under different degrees of 

vacuum. (Bouchard.) 

A Crookes vacuum tube is an apparatus wherein electrical energy is 
transformed into X-rays. These tubes present various shapes and modi- 
fications, according to the requirements demanded. The essential in 





FIG. 87. Illustrating one of the phenomena in high vacua, the rectilinear propagation of 
the cathode rays. (Bouchard . ) 

the design of an X-ray tube includes a cathode of such shape as to focus 
the cathode rays on a plate of dense metal, such as platinum, which either 
is the anode or is placed near to it. 

Fig. 88 is the illustration of such a tube. The cathode rays repre- 
sented by the shaded area focus at a point on the anode, and at this point 
12 



178 



ELECTRO-THEKAPEUTICS. 



,-rn'oot , ' 



the X-rays originate, and from it radiate in every direction in straight 
lines as light rays do from a source of light. They are represented by 
broken lines. As platinum is not transparent to them, they are found 
only on one side on the plane of the platinum and are practically of equal 
intensity throughout that zone. If the platinum plate were absolutely 
true and polished such would be strictly the case. As it is, in practice, 
the rays are of equal intensity down to about ten degrees from the plane 
of the platinum. In the majority of cases they are made of German soda- 
flint glass, which presents an apple-green color, due to the fluorescence 
produced by the X-rays under vacuum, this glass being extremely 

transparent to the X-rays. Tubes 
made of soft lead-glass give a pale 
blue fluorescence, the lead acting as 
a barrier to the passage of the rays, 
hence this kind of glass is not so 
desirable. Other varieties of glass 
fluoresce in different colors. 

The tube consists of a glass bulb 
containing a single platinum-faced 
target and one or more aluminium- 
faced cathodes. 

The anodes and cathodes are 
connected to outside terminals by 
means of platinum wires which are 
encased by the extended glass stems, 
the latter being fused during the pro- 
cess of blowing. Oiten tubes are pro- 
vided with an auxiliary anode, which 
is invariably made of aluminium. 

In order that the shadow-picture 
may be sharply defined, the cathode 
rays must converge or be focused to 
a point, and to meet this requirement the aluminium cathode must pre- 
sent a concave surface, varying in diameter from \ to 1 inch (.52.5 cm.). 
The anode ( ant i- cathode) is made of platinum, and may have a varying 
diameter, but it is usual to have its plane so adjusted as to form an 
angle of 45 degrees to the cathode. Placed in this position the anode 
behaves like a reflector, receiving and throwing off the rays emitted from 
the cathode. Platinum has a high fusing point, and it is superior in 
this respect to all ordinary metals; its use as the target for the cathode 
bombardment is because of its infusibility. Very few other metals may 
be used in its place. The most important of these substitutes is irid- 
ium, which is another member of the platinum group and has a higher 




FIG. 88. Essential features of an X-ray tube. 



THE EONTGEN BAY APPAEATUS. 179 

fusion point than platinum itself. Osmium, which is also an infusible 
metal of the same group, might be used. 

Alloys of these metals, having varying percentages, are also used. 

These infusible metals are to be backed up by ordinary metals such 
as copper and iron, because the latter are less expensive and readily pro- 
vide a large radiating surface and thermal capacity for the dissipation of 
the heat produced at the focus- point. 

The cathode is made of aluminium, because this metal disintegrates 
least and causes the least discoloration on the walls of the tube. The 
Crookes tube contains a very high vacuum, one millionth degree of 
atmospheric pressure. In order to exhaust these tubes approximately 
they are subjected to the action of mercury pumps. When a sufficient 
vacuum has been obtained, the small glass tube that projects from, and 
forms part of, the Crookes tube is removed from the pump receiver, by 
melting it off and sealing it with the aid of the Bunseu burner. 

A. THE VARIETIES OB TYPES OF VACUUM TUBES. 

(a) Stationary Vacuum. 

(b) Self -Regulating and Regenerative. 

(a) Stationary Vacuum. A tube with a stationary vacuum is one 
whose vacuum cannot be altered during its period of usefulness. This 
marks the earliest type. The Crookes tube was originally pyriform 
or cylindrical, and contained an aluminium cathode within a glass bulb. 
The cathodal streams were projected on the extreme opposite side of the 
tube, producing a peculiar fluorescence. In order to focus and subse- 
quently reflect these rays Prof. Herbert Jackson, of King's College, Lon- 
don, introduced the anode ( an ti- cathode) so as to reflect the cathode 
rays. 1 To this improved tube he applied the name "focus" tube. 2 
The priority of this modification is also claimed by Shallenberger. 3 As 
the degree of vacuum in this type of tube is liable to vary either from use 
or disuse, there is a constant danger of its permanent impairment. If 
the tube be too hard (high vacuum), there is danger of puncture, and 
impossibility of X-ray production. If the tube be too soft (low vacuum), 
the rays will lack the required penetrability. 

(b) Self -Regulating and Regenerative. In this type of tube the degree 
of vacuum is changed either automatically or by the operator, thus allow- 
ing various modifications in the penetrability of the rays. This can be 
effected by the action of gases derived from absorbent substances ; founded 
on the principle that certain chemicals, caustic potash, palladium, 

1 Jackson was the first experimenter to employ a curved cathode. 

2 Elect. Review, London, March 13, 1896 ; the Scientific American, April 4, 1896. 
'Elect. World, New York, March 7, 1896. 



180 ELECTRO-THERAPEUTICS. 

permanganate of potassium, etc., when placed in an auxiliary bulb 
(low vacuum), liberate gases upon the application of heat and reabsorb 
them upon cooling. 

In 1896, Mr. L. T. Sayen, of Philadelphia, devised a self- regulating 
tube which has been placed on the market by Queen & Co. Its principles 
are as follows : A small bulb, containing a chemical giving off vapor when 
heated and reabsorbing it when cool, is directly connected to the main 
tube, and surrounded by an auxiliary tube, which is exhausted to a vacuum 
of low resistance. In the auxiliary tube the cathode is opposite the above 
mentioned bulb, so that any discharge through it will heat the bulb by 
the bombardment of the cathode rays. The cathode is connected to an 
adjustable spark point, the end of which may be swung to any desired 
distance from the cathode (main) tube. The coil is connected as usual 
to the main tube, which has been exhausted to a very high vacuum, and 
consequently has a resistance equal to ten inches or more of air. When 
it is put in operation the high vacuum of the main tube, and the conse- 
quent high resistance, causes the current to take the path of least resist- 
ance by the spark point and the auxiliary tube, and to heat the chemical 
in the small bulb, thereby driving off the vapor which it contains into 
the main tube. This will continue for a few seconds until a sufficient 
amount of vapor has been driven into the main tube to permit the cur- 
rent to go through it, which occurs when the vacuum has been reduced, 
until the resistance of the main tube is equal to that of the spark-gap 
plus the small resistance of the auxiliary bulb. After this only an 
occasional spark will jump across the gap to counteract the tendency 
of the chemical to reabsorb vapor and raise the resistance of the main 
tube. The tube is thus maintained at a constant vacuum while running. 
When the current is stopped, the tube returns to its starting condition of 
high vacuum. 

The construction of the tube should be understood before used, and 
is as follows (Fig. 89): The large bulb U B" contains the main cathode 
and platinum reflecting plate. The regulating bulb "D" is connected 
with the main bulb "B." The cathode "C" in the main bulb is com- 
posed of hammered aluminium, moulded to an exact curve of such ra- 
dius that it focuses the cathode stream on the anode "A," which is 
composed of platinum, and is the point of emission of the X-rays. 

Bulb "B" is exhausted to a high vacuum, so that initially no elec* 
trical discharge will pass through it. Bulb ll D " is exhausted to a low 
Crookes vacuum. 

Within bulb "D" is a small pear-shaped bulb U X," in communica- 
tion with bulb "B" and containing a chemical capable of giving off 
vapor when heated and reabsorbing it when cooled. A small cathode in 
bulb U D" is arranged so that the discharge will heat this bulb "X." 



THE EONTGEN BAY APPARATUS. 



181 



Attached to this cathode is an adjusting spark-point U P," the end of 
which may be swung to any desired distance from the terminal of the 
cathode "C." 

When put in operation the high-potential secondary current will not 
initially pass through the bulb " B" on account of its high vacuum, but 
chooses a path from "K" to "P," through the bulb "D, 7 ' heating the 
chemical in the small bulb "X," causing vapor to be given off and re- 
ducing the vacuum in the main bulb "B" until finally it becomes suffi- 
ciently lowered so that the discharge passes through the bulb "B" 
entirely, producing X-rays from the plate u A. " 

Let the spark-point U P" be separated about three (3) inches from 
terminal "K." Start coil with small current flowing through primary 
until sparks begin to jump vigorously between "P" and U K." Then 



Terming! 




K--- 



FIG. 89. Queen's self-regulating tube. 

open the primary circuit without changing its adjustment. Immediately 
close again for a second or so, the spark passing from "P" to "K" 
through and lighting up the small regulating bulb " D." Continue, alter- 
nately, opening and closing the primary circuit, allowing the regulating 
bulb "X" to heat slowly until a green light begins to show in the main 
bulb "B." Hold primary circuit open for a second or two, close, and 
the bulb "B" will then automatically maintain its vacuum at the set 
point, the primary current may be increased to the full capacity of the 
tube, while only an occasional spark will pass between "P" and U K." 
If the bones appear in fluoroscope too black, make the gap between " P" 
and "K" greater. If not enough distinction between bones and flesh, 
make less. 

When tube is running properly, the main bulb will be filled with a 
brilliant green light, with a sharp-cut zone through the plane of the 
platinum plate, the upper section being more brilliant than the lower. 



182 ELECTRO-THERAPEUTICS. 

Miiller, of Hamburg, aud E. Ducretet,of Paris, have brought forward 
a tube, resembling iu many respects the Sayeu tube, but differing from it 
in that the regulating discharge passes directly into the auxiliary tube ; 
the latter containing caustic potash. (Fig. 90. ) When the vacuum in the 
main tube becomes too high, and consequently the resistance too great, 
the current passes into the auxiliary chamber, whereby the potash be- 
comes heated and emits vapor ; this vapor diffuses itself through the main 
tube, thus lessening the too great resistance. Attached to the auxiliary 
circuit is a lever that regulates the interval of the spark-gap ; the more 
distant the lever from the cathode of the main tube, the higher the vac- 
uum in that tube ; the nearer the cathode, the lower the vacuum. 

Should the resistance in the main tube be in excess of that of the 
spark-gap, the current takes the path of lesser resistance and passes 




FIG. 90. Miiller'3 regulation tube. 

through the side tube. The presence of sparks in the spark-gap shows 
that the process is proceeding. Should the vacuum in the main tube be- 
come too low (soft), disconnect the wire from the anode of the main tube 
and attach it to the terminal of the electrode iu the auxiliary chamber. 
The discharge that passes under this adjustment causes metallic particles 
to be driven against the sides of the tube and the generation of more gas 
to be occluded on the electrode (auxiliary). Thus the vacuum of the 
tube may be materially raised. 

In order to clarify the above statements, it may be stated that the 
auxiliary tube " B " contains an electrode, " C," of a substance which will 
give off a certain quantity of gas by the electric discharge passing through 
it, and will thus lower the vacuum. This is effected by approaching the 
wire "E" to the cathode U K" and thus permitting the spark to pass. 
In case an even degree of hardness is to be maintained, the distance of the 



THE RONTGEN KAY APPARATUS. 



183 



wire u E " from u K " for hard rays (diagrams of the pelvis) L-j 10-11 cm., 
for soft rays (diagrams of the hand) 5-7 cm., for treatment even less. 
The working of the u Miiller regulation" may be observed by the sparks 
passing between "E" and 



"K." As soon as this 
stops, the tube has the de- 
sired degree of vacuum and 
will maintain the same au- 
tomatically by an occasional 
spark jumping over and 
reducing the vacuum, as 
soon as the latter shows a 
tendency to rise. In case 
the automatic way of lower- 
ing the vacuum should re- 
quire too much time, it can 
be hastened by either ap- 
proaching the wire "E" 
even closer to " K, " or 
finally connecting the nega- 
tive pole to the loop "C." 
In this latter event special 
caution is recommended, as 
tubes easily become too 
soft and a hardening is 
more difficult. 

Hardening a tube is 
effected by changing the 
positive pole from '-G" to 
"J" and removing the 
wire "E" far off from 
"K." When the current 
is now turned on, it will 
scatter atoms of the metal 
of the electrode u J," thus 
reabsorbing part of the gas 
of the tube. This process 
requires up to 5 minutes, 



B 



H 




FIG. 91. Monopol tube. The vacuum may be altered 
during the process by the generation of air through the 
disconnection of the movable conductor "Z," or by the ab- 
sorprion of air through the disconnection of the movable 
conductor "H." The flexible wire "Z" is raised for some 
seconds by means of an isolated rod until a spark leaps over 
to the auxiliary cathode at "B," by means of which air is 
generated and the resistance of the tube lowered. Tubes in 
which the degree of generation has become excessive are 
modified by raising the movable conductor " H " as shown in 
the sketch. Air is generated by the disconnection of the 
flexible conductor "Z" and the leaping over of sparks to 
"B," and accordingly the degree of the vacuum in the tube 
is lowered. Air is absorbed by disconnecting the flexible 
conductor " H," and the resistance of the tube is increased. 



according to the vacuum, 
and may have to be repeated. It is not advisable to change the vacuum 
of a tube too often. For different purposes different tubes should be em- 
ployed. Tubes of varying construction have recently been brought forth 1 

1 Archives of Physiological Therapy, September and October, 1905. 



184 ELECTKO-THEKAPEUTICS. 

that are worthy of brief mention. The Mouopol tube made by Hirsch- 
mann of Berlin is especially devised for easy regulation of the vacuum 
without interruption of the X-rays. (Fig 91.) Using a spintermeter 
with ball terminals, he finds that each centimeter of spark equivalent 
practically corresponds, with this tube, to the same number of the Beuoist 
scale of penetration. It is a bianodal tube, with a separate bulk at the 
cathode end for lowering, and another at the anode end for raising the 
vacuum, and either of these may be caused to operate by simply pulling 
its movable arm with an insulated hook. This may be done while the 
tube is in operation. 

Heinz Bauer has made X-ray tubes in which the rapid raising of 
the vacuum, due to the pulverization of the platinum anti-cathode is pre- 
vented by causing the current to pass mostly to the anode. To this end, 
the anode is pointed and contains quite a mass of metal ; besides this, a 
regular small self-induction coil is placed between the external connec- 
tion of the anode and that of the anti-cathode. Another of Bauer's tubes 
has a heavy corrugated copper stem for the anti -cathode, dissipating heat 
inside the tube, and also externally, through a reentrant glass tube which 
forms a part of it. 

Method by Osmosis. (Fig. 92. ) This method depends upon the prin- 
ciple that heated platinum possesses the property of being penetrable 
by hydrogen. A closed tube of platinum is sealed into the bulb of the 




FIG. 92. Osmosis regulating tube of Gundelach. 

X-ray tube. When it is desired to lower the vacuum in the tube, the pro- 
jecting platinum tip is heated to redness in a Bunseu flame. The heated 
platinum permits the passage of gas through its pores into the tube, thus 
lowering the vacuum. This process may be resorted to without inter- 
fering with the working of the tube ; the degree of vacuum can thus be 
gauged by the color of the fluorescence. A low vacuum is manifested 
by a bluish tint, indicating that the heating of the platinum should 
cease. 

Mechanical Regeneration. This method allows of a variance in the 
penetration value, by adjusting the distance between anode and cathode. 
Its employment, however, is inapplicable, as it entails the sacrifice of 
many tubes and requires an adept in manual dexterity. 



1'LATK I. 




SELF-REGULATING X-RAY TUBE. OPERATING PROPERLY. 
(FIG. 93.) 



THE ROXTGEX RAY APPARATUS. 185 

Electro -static Regeneration is founded 011 the principle that the dis- 
charge passing through a focus tube is influenced by the charge generated 
by electro-static induction on the outer surface of the tube. To accom- 
plish this, the neck of the tube in the plane of the cathode edge is 
covered with strips of tin-foil, and by connecting it by an adjustable 
spark-gap with the ground or wire leading to the cathode. The method 
gives some promise of usefulness, but the serious drawback is, the con- 
stant danger of perforation of the tube. 

Water-cooling tubes are those in which a stream of running water 
passes around the anode, maintaining it in a cool condition, thus not 
interfering with the degree of vacuum in the tube. In other tubes there 
may be two anodes ami two cathodes, which are adapted for the use of 
the alternating current. 

B. THE QUALITY or THE X-RAYS. 

The qualities of the X-rays depend largely upon the apparatus and 
the degree of vacuum of the Crookes tube. Thus, while the quantity of 
the electrical energy influences the intensity of the rays produced, the 
condition of the tube is the predominating factor when a constant and 
powerful supply of X-rays is required. Tubes are thus said to be 
"soft," "hard," or "medium." 

A tube is said to be "soft" when the degree of vacuum is low, thus 
offering less resistance and allowing the current to pass easily, but with a 
diminution in the intensity and likewise in the penetrability of the rays. 

In a "hard" tube the degree of vacuum is high, resistance is there- 
fore increased, and a greater obstacle is presented to the passage of the 
discharge. The radiation gains thereby in intensity, as also does the 
penetrative power. 

The "medium" tube occupies a place intermediate between the 
"hard" and the "soft." 

J. M. Eder and E. Valenta 1 observed that the effectiveness of a tube 
varied with its degree of vacuum. 

Porter 2 thus classifies the rays: 

X i -rays penetrate the soft parts easily, but the bones with difficulty. 

X 2 -rays, those absorbed by the soft tissues. 

X 3 -rays, those readily penetrating both soft tissues and bone. 

Albers-Schonberg 3 considers four degrees of vacuum : 

1, hard (gray). 3, soft (deep-black). 

2, medium soft (gray -black). 4, very soft. 

1 Vers. u. d. Photo, mittelst der Rontgenstr., Wien und Halle, 1896, p. 5, Anna. 
1 Quoted by Valenta, Oest. Chemikerztg., I. Nr. I. 1898. 
'Fortschr. a. d. Geb. d. Rontgenstr., Bd. iii., H. 4, p. 143. 



186 ELECTRO-THEEAPEUTICS. 

The intensity of the shadows of the metacarpal bones on the fluor- 
escent screen is taken as an index. 

Kienbock recognizes a fifth grade, the " over-hard" tube. 1 

The success in skiagraphy most largely depends upon the quality of 
the rays and the behavior of the focus-tube. 

Until the present time, although the form, size, etc., of the tube 
have steadily improved, the majority of operators will sustain me when I 
assert that in order to make a good skiagram the knowledge of the degree 
of the penetration of the rays is most essential. 

I have enumerated the various methods for ascertaining the approxi- 
mate penetrability (quality and quantity) of the rays, but those methods 
are as yet quite crude. This subject is fully treated of under Rontgeu 
Bay Therapy. 

The degree of the vacuum of the tube changes during or after 
active work, so that the operator cannot predict exactly the degree of 
penetrability of the rays ; hence the time of exposure still remains 
uncertain. 

Testing the rays with the fluoroscope by the shadow of the bones 
of the hand is most dangerous, and is virtually not employed to-day 
except by some of the inexperienced and most careless. The osteoscope 
of Carl Beck substitutes the skeleton hand for the human hand, but this 
is injurious to the eye, no matter how well the latter is protected with 
lead (flint) glasses. 

Fluorescence of the tube is an inexact measure, and the degree of 
redness of the anode is unreliable. Each tube behaves differently with 
different types of interrupters, currents, and coils. 

Spintermeter or Parallel Spark-gap. The length of the spark-gap va- 
ries with different voltages of current, the shape of the spark-gap, the 
winding of the coil ; the degree of the vacuum of the tube or its resistance 
cannot be ascertained because of the distance of the anode from cathode, 
and the varying sizes of the latter may cause more or less resistance. 

I have tubes that back up 4 to 5 inches (10 to 12.5 cm.) parallel 
spark-gap, and yet produce cathode rays bluish in color and conical in 
shape, which are useless for penetration ; therefore the resistance of the 
tube does not always indicate the penetrability of the rays. 2 

C. CARE OF THE TUBE. 

Before using the tube see that it is absolutely free from dust particles 
by employing some soft fabric as a wiper, exerting as little pressure on 
main bulb as possible. The tube should always be perfectly dried by 
allowing the heat from a gas jet to pass around it. 

1 Wiener klin. Woch., 1900, No. 50. 
'See Part III., Chapter IV. 



PLATE II. 




SELF-REGULATING X-RAY TUBE. CURRENT RUNNING IN WRONG 

DIRECTION. 

(FIG. 94.) 



THE RONTGEN RAY APPARATUS. 187 

The leads from the terminals of the secondary coil should be per- 
fectly insulated and sufficiently separated from one another through- 
out their entire length to prevent any sparking between them. These 
wires must not come in contact with any conducting material, which 
would naturally permit of leakage of the current. The conducting wires 
should be sufficiently distant from the surface of the tube to prevent 
puncturing. Such a puncture is usually from a spark jumping through 
the glass wall from the conducting wire to the electrode within the tube 
of opposite polarity. Puncture of the tube renders it useless, in some 
cases presenting an immediate change of color. Sparking occurs between 
the anode and cathode from the inrush of air ; in other cases the injured 
tubes may be worked for two or three hours after the accident. If the 
auxiliary bulb lights blue or red, the vacuum is low and a puncture or 
leak may be suspected. (Fig. 97. ) 

In operating a tube see that the current is sent into it in the proper 
direction, or blackening will soon occur on the inside, manifesting itself 
by disintegrating platinum particles. Should the current conductors be 
connected to the tube in reverse order, the error will be recognized by a 
brilliant jumping fluorescence around and behind the platinum target. 
With proper connections there is a steady fluorescence of the hemisphere 
in front of the anode. As the X-ray apparatus is provided with a com- 
mutator, the current can conveniently be reversed without altering the 
connections and position of the tube. Figs. 93 and 94 illustrate the 
proper and the wrong connection of the tube. 

Blackening of the Tube. As already mentioned, blackening of the 
tube often results from the i ' inverse' ' current, but this can be avoided by 
placing the spark-gaps in u series" of intervals of two or three inches 
either in one or both ends of the terminals. 

Lately I have seen the whole inner surface of the tube darkened by 
an impure alkaline substance thrown off from the auxiliary bulb. The 
tube was opened, and, by the aid of an acidulated solution, the substance 
causing the discoloration was dissolved, showing that the blackening was 
not due to disintegrated platinum particles, but to the impurities of the 
potash in the auxiliary bulb. Had this blackening been caused by the 
disintegration of the anode, the discoloration would have been manifested 
only at the active hemisphere. 

In place of the spark-gap in " series," Yillard urges the employ- 
ment of a ventril tube with a proper degree of vacuum for the current, 
instead of its passage through the air. (Fig. 95.) By employing the 
ventril tube the current becomes unidirectional, the rays have a 
greater penetrative power, blackening is minimized, and the " life " of the 
tube is prolonged. I find the self-regulating ventril tube to be eminently 
satisfactory. 



188 ELECTEO-THEEAPEUTICS. 

Puncture of the Anti-cathode. This accident occurs only in tubes 
with very thin and non-supported anodes ; especially did puncture of 
the anti-cathode happen when the Wehnelt interrupter first came into 
use. This difficulty has been overcome by increasing the thickness of 
the anode, and also by reinforcing it in back by means of copper ; like- 
wise by making the converging cathode rays fall at a point a little in 
advance of the anode. 

Explosion of the Tube. When a tube is accidentally broken, the 
sudden inrush of air produces a report resembling that accompanying 
the explosion of a firecracker. I believe the term "explosion" is a 
misnomer; the substitution of the term " collapse" would appear to me 




FIG. 96. Villard's ventril tube. 

to be more correct, for the general breaking up is more likely the result 
of external atmospheric pressure than due to any force created inter- 
nally. In the experience of years I have never suffered the explosion of 
a tube. 

The "life" of the tube depends largely on the amount of its use, 
and the care in manipulation bestowed upon it. The metallization of 
the tube interferes in no manner with its working. 

In regard to the consumption of tubes by the use of small and large 
inductors the conclusions reached by Albers-Schonberg are of the greatest 
practical importance. He has kept a complete record of the use of each 
tube and the conditions under which it was used, and concludes that the 
life of a tube used with an 80 cm. coil is more than three times as long 
as when used with a 40 cm. coil. The small coil used in this instance 
was the Dessauer instrument. At the same time he found that the work 
done by the tube in connection with the large coil was more satisfactory. 
In order to get the desired results with the small coil it was necessary to 
use a ventril tube in series with the Eontgen tube, while with a large 
coil none was used. 

When the vacuum becomes so high or so low (Fig. 96) that it is 
unsuited for the operator's purpose, and his efforts to restore a proper 
vacuum are unavailing, the only remedy is a repumping of the tube by 
the manufacturer. 



1'LATE III. 




SELF-REGULATING X-RAY TUBE. LOW VACUUM. 
(FiG. 96.) 



THE EONTGEtf EAY APPAEATUS. 189 

III. The Fluoroscope and Accessories. 
A. CONSTRUCTION OF THE FLUOROSCOPE. 

The fluoroscope, also called cryptoscope and iristoscope, was devised 
and first described by Professor Salvini, of Rome. 1 It consists of a dark- 
ened chamber, having the shape of a photographic camera. At the 
larger end is fixed the fluorescent screen; at the smaller end is an opening 
(fitting the examiner's forehead) through which the shadows on the 
screen may be observed. With a fluoroscope a darkened room is unnec- 
essary. The majority of fluoroscopes are provided with a handle for 
holding the apparatus. More recent ones are so constructed as to permit 
of the easy removal of the screen. (See Fig. 104. ) 

The fluorescent screen mentioned above consists of a coating of 
platino- cyanide of barium, spread evenly upon a supporting sheet. A 
layer of varnish is carefully applied, so as to prevent this fluorescing 
material from falling off, and likewise to keep it dry. As the fluores- 
cence of the screen is not very brilliant, a dark room must be employed, 
otherwise rays of ordinary light will interfere. The screen being adjusted 
in the frame, the chemical surface further protected by isinglass, and 
the light excluded from the tube by means of black paper, beautiful 
shadows are portrayed by placing the object between the tube and the 
screen. When not in use the screen should be kept free from dust and 
moisture. 

There are other chemical agents besides those mentioned which pos- 
sess fluorescent properties and are adapted for screens. Thus Edison, who 
examined 1800 chemicals, 2 found that tungstate of calcium fluoresced with 
six times more intensity than platino-cyanide of barium; next in bril- 
liancy was tungstate of strontium. Salicylate of ammonium (crystals) 
fluoresces as much as double cyanide of potassium and barium j the 
former's fluorescence, however, increases with the increase of the thick- 
ness of the crystal layer. Other substances that fluoresce under the ac- 
tion of the rays are mercurous chloride, cadmic iodide, calcium sulphide, 
potassium iodide, potassium bromide, etc. 

The only two of the many fluorescent salts employed in the manufac- 
ture of screens are platiuo-cyauide of barium and calcium tungstate. The 
former affords a brilliant yellowish-green fluorescence, the latter a less 
intense bluish-white. This bluish white fluorescence offers a greater 
photo-chemical activity, and is therefore employed as an intensifying 
screen in radiographic work. Under the name of "the collapsible 
cryptoscope," H. W. Cox & Co., Ltd., of London, have placed upon the 

1 Proceedings of the Accademia Medico-Chirurgica di Perugia, vol. iii., No. 1-2 ; 
also the Scientific American, March 28, 1896. 

2 Elect. Review, New York, April 19, 1896. 



190 ELECTKO-THEKAPEUTICS. 

market a fluoroscope, which apparatus is fitted with accordion folds, 
that readily permit of easy adjustment. This cryptoscope has given 
satisfaction, but its exorbitant price makes its general employment 
prohibitory. 

B. SKIAGRAPHIC TABLE. 

Lately I have made several improvements upon the Scheidel- Western 
table which may be described in the following manner : 

As to the Scheidel table : This is a solid table and has a leaf at the 
head-board that can be raised and lowered. It is operated solely from 
one side of the table, allowing the opposite side free of encumbrance. 
To the former side are attached two horizontal metallic tubes, the upper 
of which is cogged and terminates at the foot-board in a crank, which 
allows the tube-holder to advance or recede at the will of the operator. 
The tube-holder is also provided with a crank, which allows of its lower- 
ing or elevation, upon the same principle. The tube-holder carries a glass 
shield for the reception of the focus tube, the horizontal portion of the 
tube-holder being so jointed as to allow free movement in the direction 
of a circle or at any angle at the disposal of the operator. I have sug- 
gested the following improvements : 

A dome-shaped portion of the table capable of being immediately 
removed is a valuable feature in so far that the patient may enter this 
opening w r hilst the piece of board that has been removed may be locked 
in grooves at the foot of the table, thus acting as a plate holder. In this 
position skiagrams of the stomach, chest, and sinuses may be taken. 

This table answers for all purposes of the Rontgenologist ; namely, it 
combines a compression diaphragm, a stereoscopic apparatus, and an 
auto- condensation couch for high-frequency currents, whilst the glass 
shield acts as a protective to operator and patient. 

C. HOFFMAN'S MEASURING STAND AND EXAMINING FRAME. 

This consists of two uprights firmly secured to a platform, and sup- 
porting the square or rectangular shaped measuring frame which can be 
shifted up and down or to the right or left, by turning a few thumb-screws. 
The adjustable frame is subdivided into smaller squares. The dividing 
cross-bars are so constructed as to permit of their being shifted into any 
position and their exact location noted by reading the metric scales at 
the sides. Accessory frames are placed at the outside of the uprights ; 
one of these acting as a plate- receiver for a skiagram, another supports 
the fluoroscopic screen for a visual examination. 

Lately I devised a table that meets the requirements for skiagraphy, 
stereo-skiagraphy, and X-ray treatment. (See Figs. 183 and 184.) It is 



PLATE IV. 




SELF REGULATING X-RAY TUBE. PUNCTURED OR CRACKED. 
BULB PARTIALLY FILLED WITH AIR. 

(FIG. 97.) 



THE EOKTGEN BAY APPARATUS. 191 

made of wood, and upon the two parallel horizontal metallic tubes, two 
vertical metallic rods move to and fro, the latter supporting a horizontal 
sliding bar of wood, from which is suspended the tube-holder. For skia- 
graphy the tube can be placed under the table, over the table, or in any 
position in relation to the patient's body. The table is provided with 
an adjustable plate-holder. The device can be regulated so as to be 
adapted to any sized plate ; it is attached to the vertical rods. This plate- 
holder with the plate is placed over the part, with the tube beneath the 
table, or in the sitting posture the plate is placed against the part, and 
the tube behind the patient. In stereo-skiagraphy the plates can be 
changed without employing the usual drawer. For treatment, the tube 
is placed in a leaden lined wooden box, having an adjustable diaphragm 
with any required sized opening, which is regulated by sliding the mov- 
able pieces of wood composing it. The bars and tubings are scaled in 
inches and centimeters to facilitate the ease of measurements required of 
the operator. 

D. TUBE-HOLDERS. 

These are of various kinds. For clinical purposes it is essential to 
have a stand, in order that the tube may be adjusted to any desired height 
from the floor, at the same time allowing it to project far enough to en- 
able to operator to shift it at ease over the examining table or couch. 
The base must be heavily weighted, to insure steadiness, and the project- 
ing arm must be firmly clamped. The latter is made of wood or ebonite 
to prevent any spark from the terminals passing into the metal and thus 
perforating the tube. Loose clamping must be studiously guarded 
against ; lack of this precaution will produce a blurred photograph, as 
the swinging tube is made readily tremulous by the amplification of any 
motion communicated to the stand and arm. 

Lately I devised a tube-holder in my office made up as follows : A 
shelf, made of two horizontal bars grooved in their interior, is bracketed 
upon the wall. Along these grooves slides a block of wood (the carriage). 
To this carriage is attached a projecting bar of wood, whose angle may 
be varied at pleasure by adjusting the thumb-screw maintaining its rela- 
tion with the carriage. By means of an adjustable screw, a second block 
of wood (transverse to the long axis of the projecting bar) is made to slide 
to and fro at the will of the operator. Through this latter bar runs the 
metallic rod, supporting the tube-holder. By means of this holder, free- 
dom of movement is so obtained that the principles of the universal joint 
are faithfully portrayed. With this tube-holder the table is dispensed 
with, and a couch or sofa is substituted upon which a board is placed if 
necessary, for supporting the sensitive plate. (See Fig. 200.) 



192 ELECTRO-THERAPEUTICS. 

E. Box- COVER FOE X-RAY TUBE. 

This consists of a wooden box covered on its inner surface by a thick 
coating of lead oxide. On one side of this box is a hole (4 to 5 cm. in 
diameter) for the transmission of the rays. This circular aperture is 
shielded by a wooden diaphragm of heavy sheet lead, having three differ- 
ent sized apertures, and by adjustment the desired opening can be brought 
in direct line with any part of the body. Luminous effects are excluded, 
and the dangers of burning by the rays are reduced to a minimum. It 
must be remembered that the diameter of the rays (cone-shaped) 
increases as the distance the tube is placed from the patient. 

In some tube boxes, instead of the lead foil, several layers of lead 
paint are used for coating the interior of the box. The size of the box 
varies in different models. In some instances they are made so large as 
to be an inconvenience, while in other cases they are too small to secure 
perfect insulation. 

F. DIAPHRAGM. 

The diaphragm was formerly used for sharpening shadows on sensi- 
tive plates. It may be made of metal or glass, with an aperture in the 
centre for the transmission of the rays. In the glass variety, the excess 
of lead acts as an obstacle to their passage, the rays being almost wholly 
transmitted through the aperture. If the diaphragm is metal, it should 
preferably be grounded, to obviate the danger of puncturing the tube by 
sparks jumping from it. The object of the diaphragm is to prevent the 
passage of the rays to other parts than those examined. 

Compression Diaphragm. This appliance, devised by Albers-Schon- 
berg, consists of a metallic tube, having one end applied against the part 
to be skiagraphed, and the other end so adjusted as to receive the rays 
emanating from the Crookes tube. By its use we secure immobility of 
the part, mechanically lessen the thickness of the structures under exami- 
nation, and totally exclude all the secondary rays. (Fig. 99.) In Fig. 
98 is illustrated the ordinary diaphragm, wherein is depicted the passage 
of the indirect rays, b 6, affecting that portion of the plate indicated by 
the slanting parallel lines ; this is entirely obviated in the compression 
diaphragm, where a a are the direct rays from the anode. (See also Figs. 
192 and 193.) 

Dr. Henry Hulst 1 states that the use of this diaphragm is most valu- 
able in the skiagraphy of renal, spinal, and pelvic conditions. Thus, in 
cases of suspected renal calculi, the employment of the compression dia- 
phragm materially lessens the number of diaphragmatic movements of 
the patient, and as the kidney moves with each movement of the patient' s 
diaphragm, the steadiness of the kidney is markedly increased, in conse- 
quence of which, a skiagram of a renal calculus will not be blurred. 
1 Transactions of the American Rontgen Ray Society, September, 1905. 



THE EONTGEX EAY APPARATUS. 



193 



The serious disadvantage of the compression diaphragm is the fact 
that only a very small area can be skiagraphed at one time, while the 
stone searched for may be located outside the part covered by the cylin- 
der. This method prevents a negative being taken of both sides for the 

of comparison ; a most necessary and invaluable guide. 



II 




FIG. 98. Ordinary diaphragm. 



FIG. 99. Tubular or compression 
diaphragm. (Donath.) 



Although largely used in Europe and America, I do not advocate 
the employment of a compression diaphragm, as, with greater refinements 
in the technic, the time of exposure has been so materially lessened that 
there is a marked decrease of the secondary rays, and without the 
diaphragm a large area is exposed for examination on the plate. 

IV. The Selection and Installation of X-ray Apparatus. 
A. SELECTION OK CHOICE. 

In equipping an X-ray laboratory several factors must be considered. 
The scope of the work, the portability of the instrument, the necessary 
expenditure that will be incurred, the requirements of the apparatus for 
the office, the city or country hospital, and the fact whether the purchaser 
is an X-ray specialist or a general practitioner. 

By the scope of work to be accomplished we mean the extent of use- 
fulness of an X-ray outfit. A small coil will suffice for the work that a 
beginner may be required to do, but the purchase in the beginning of a 
large coil, which will prove more lasting, is wisest because increase of 
work will early demand this improvement in the apparatus. 

Hospital (City or Country). In the majority of city hospitals a 110- 
volt current is supplied for working a coil. The coil that is installed 
in the laboratory of a large city hospital should have a spark length of 

13 



194 ELECTRO-THERAPEUTICS. 

from 12 to 20 inches (30 to 50 cm. ). It should be so constructed as to be 
capable of conveyance to the various parts of the hospital. The coil 
can be worked by attaching a connecting head to one of the electric light 
sockets from which leads extend to the coil. If the hospital is not lighted 
by electricity (110- volt current), it becomes necessary to prepare a place 
on the main shelf of the carriage, or on the second shelf, for placing a stor- 
age battery, by which means the coil then must be worked. "When patients 
can be conveyed from the bed to the laboratory, much labor is saved. 

In country hospitals and sanitaria, where there is difficulty in obtain- 
ing either continuous or alternating current, static machines are recom- 
mended for exciting the Crookes tube, and also for therapeutic purposes. 
For exciting a tube the use of a water motor or a small gasoline or gas 
engine must be resorted to. If expense be a matter of moment, I then 
recommend a coil worked by a secondary battery. The physician's or 
surgeon's outfit should be portable. He should employ an 8- to 10-inch 
(20-25 cm.) spark, worked by a storage battery. For examinations in 
a private office the use of a static machine (run by an electric motor), in- 
stead of a coil, is recommended. The expert should have in his posses- 
sion an outfit capable of meeting all emergencies. It should consist of 
two coils and a static machine. In his private office he should have a 
stationary coil with a spark-producing power of from 18 to 22 inches 
(45 to 55 cm.), and a second coil so constructed and arranged as to allow 
of its ready transportation, the latter to be capable of giving a spark 
from 8 to 10 inches (20-25 cm.) long. This portable coil should be 
worked with a storage battery. 

Portable X-ray Outfit. It seems pertinent, just here, to digress for a 
moment, to say a few words relative to the so-called portable outfit. I am, 
and have been, deluged with inquiries bearing on this subject. I realize 
the fact that there are on the market several good and convenient portable 
transformers, that appeal most attractively to the general practitioner. 
According to the statements of the manufacturers, these transformers can 
produce equally satisfactory currents, whether for the X-rays, high-fre- 
quency, or violet ray applications. I cannot, however, endorse such views. 
To me it does not seem plausible that any one machine can give all of these 
various currents with equal degrees of satisfaction. For heavy work and 
to meet the exigencies of the Rontgenologist, I believe that special 
apparatus adapted for each particular purpose is indispensable for the 
accomplishment of the best possible results. 

B. INSTALLATION. 

It remains to give a brief r&sume" of the arrangement and manage- 
ment of the different parts concerned in the production of a skiagraph. 
The first essential is to determine the nature of the current available. 



THE RONTGEN RAY APPARATUS. 



195 



The coil can be energized by an accumulator or by tlie continuous or 
alternating current from the street supply. In the latter instance the 
transformer is necessary to reduce the enormous voltage. Some place the 
coil upon the table ; my own preference is to rest it upon a shelf attached 
to the wall, thus space is saved and the operator is kept away from the 




FIG. 100. AUTHOR'S TABLE AND TUBE-HOLDER. The pulley moves the tube-holder to and fro. 
The ventril tube is connected in series with the Crookes tube and lessens the " reverse current," whose 
vacuum can be lowered, at pleasure, by the operator compressing, at a distance from the tube, a bulb, 
which drives a blast of air into a gas flame, thus allowing the heating of the platinum in the ventril 
tube. 

magnetic field. The latter method is prevalent in Germany. The con- 
trolling apparatus (the interrupter, rheostat, switch-board, etc.) should 
be within easy reach. After installing the coil, the source of current can 
be connected with it by the use of the switch-board. The switch -board 
is provided with several binding posts, the latter being connected with 



196 



ELECTRO-THEKAPEUTICS. 

x\V'// 




THE RONTGEN KAY APPARATUS. 



197 



the accumulator and likewise with the direct current. A double switch- 
thrower connects the current with either the accumulator or the direct 
current. Another switch can be made to connect the current with either 
the mechanical interrupter or the Wehnelt break. For charging the 




FIG. 102. Author's office outfit. 



accumulator a bank of lamps is provided ; the remainder of the switch- 
board is made up of the fuses, the ammeter and the voltmeter. The 
author's table and tube-holder and method of installation are illustrated 
in Figs. 100, 101, and 102. 

C. POLARITY AND CONNECTION OF TUBE. 

Next to be considered is the connection of the terminals of the sec- 
ondary coil to the tube. To do this properly it is necessary to ascertain 
the polarity. The following methods may be applied : 

(1) Dip the ends of the two wires into dilute sulphuric acid or 
water. The negative wire shows a free development of gas; this does not 
occur with the anode, which is colored black from the deposition of 
copper oxide. 

(2) Moisten the paper with potassium iodide, bring the poles in 
contact with it; the presence of a black stain indicates the anode. 

(3) By means of a small tube filled with a liquid into which plat- 
inum wires project; the application of a negative pole is followed by the 
liquid being dyed a red color. 

(4) The polarity can also be determined by the peculiar color of 
the spark on the terminal electrodes of the secondary coil ; the cathode 
shows the presence of a thick, whitish spark, while the anode shows 
several wiry lines of spark of a pink color. (Fig. 103.) 



198 



ELECTEO-THEK APEUTICS. 



The leading wires should be connected with the proper terminals of 
the tube by thin, well -insulated copper wire. This connection to the 
terminals should be provided, on each side, with at least one inch of 
spark-gap. The wires should be separated at a distance from each other, 
from the tube, and also the patient, greater than the length of the parallel 
spark gap (where the wires are attached to the tube they are supported 
by a noil -conductor). The current must not be turned on before all <<:: 
nections are completed, else there is danger of severe shock both to the 
operator and the patient. Wrong polarity can be easily determined by 
the appearance of the tube, and corrected by the commutator. 

After the polarity has been ascertained the ends of the tube may be 
connected to the respective terminals. The connecting wires should be 
thickly coated with gutta-percha to prevent leakage and also possible 
puncture of tube. There should exist multiple spark-gaps in series, as 




FIG. 103. The polarity as determined by the appearance of the spark. 

this device improves the quality of the rays and prevents or lessens the 
" inverse " current within the tube. After the tube has been lit up, the 
spark-gap between the ends of the tube and the brass balls should l>e 
adjusted until the best results are obtained. 

Advantages of the Static Machine. The static machine requires little 
attention and is nearly always ready to generate electrical energy, of a 
high potential. The current is almost perfectly continuous through the 
tube, and hence the illumination of the fluoroscope is steady. The radi- 
ation and the penetration of the rays of the tube may be modified by 
varying the interval of the spark-gap (in series). The static current 
may also be used as a therapeutic agent. 

' Disadvantages of the Static Machine. -Should the beginner purchase a 
coil or a static machine for X-ray work ? A definite answer cannot be 
given unless the scope, kind, and the place of work be considered. I 
employ both the static machine and the coil, the static for electro-thera- 
peutic purposes, and the coil for X-ray work. I have stated the merits 
and demerits of the static machine ; the converse of these assertions holds 




FIG. 103A. Wagner's automatic switch. 




FIG. 103B. TIME SWITCH. This time switch may be used to stop automatically the coil, static 
machine, vibrator, or therapeutic lamp at the end of a treatment : especially valuable where two or 
more patients are treated at the same time. The switch proper is of the single pole knife variety. The 
contacts are substantial and there is no possibility of sticking. I found it very satisfactory in my 
practice. 



THE RONTGEU KAY APPARATUS. 199 

good for the coil. If the leads are freely '-brushing" the tube may be 
seriously interfered with. These brush effects fill nervous patients with 
fear; hence it is difficult to keep them steady for a sufficient length of 
time required for the exposure. It must l)e remembered that a small am- 
perage of static current does not produce the necessary penetration for 
good skiagraphic or fluoroscopic effects of the deeper structures of the 
body, nor is it adapted for short exposures ; this can be partially reme- 
died by augmenting the number of plates or by increasing the speed. 
If non-breakable plates are employed, the speed of revolution may be 
increased manifold, without increasing the number of the plates, and 
the deficiency is thus overcome in X-ray work. Other objections that 
may be urged against these machines are their bulkiness and the sudden 
and frequent changes in their polarity and failure to work in damp 
weather. 

Automatic Simtch for X-ray Work. Dr. E. V. Wagner, of Chicago, has 
devised a new automatic time switch which is very simple in operation, and 
can be depended on to stop the treatment, when the time is up, by cutting 
off the current. This not only makes the physician's presence unnecessary 
during the time of treatment, but also relieves the patient from the anxiety 
caused by fear of too long an exposure because of the physician's absence. 

In using either the X-ray or other forms of electricity in therapeu- 
tics, the inconvenience and loss of time required to estimate properly the 
length of treatment is an annoying feature of the work, especially so 
when the X-rays are used, as the length of exposure is of the utmost im- 
portance. The safety of the patient requires that over-exposure be 
avoided, and safety to the operator demands that he should not remain 
present longer than necessary, even when ordinary protection is employed. 

The switch is controlled by a clock, the face of which is equipped with 
a movable ring holding a contact point which may be placed a fraction of 
a minute, or as many minutes as desired, ahead of the minute-hand for the 
length of treatment to be given. When the minute-hand reaches the con 
tact point, the current from the dry cells in the sub-base causes an electro- 
magnet to release the knife switch, which flies open, cutting off all current 
to the apparatus. The switch, when closed, is held by a clip, and is so 
designed as to permit of its being used independently of the automatic time 
device. The switch proper can also be taken off the sub-base and used as a 
substitute for any other switch, while the sub-base carrying the clock and 
holding the cells may be put at any convenient place. As the switch may be 
used for any kind of current, for coil equipment, with static machines, wall 
plates, sinusoidal apparatus, etc., it will afford a means of saving time and 
responsibility for one who uses X-rays or electro-therapy' ' l (Fig.103 A and B) . 

1 In 1906 at a meeting of the American Medical Association which met at Boston, 
before the section on Therapeutics I reported that I had devised an automatic switch 
identical in principle with this later apparatus of Wagner. 



CHAPTER II 
THE PRINCIPLES OF TECHKLC. 

I. Fluoroscopy. 

HAVING briefly described the X-ray apparatus and the modes of its 
manipulation, we shall now dwell upon the methods of its practical 
application. 

When conducting such examinations, it is essential, though not 
absolutely necessary, to have the room darkened so as to exclude ordi- 
nary light. Of course the rays are invisible. The means employed 
for detecting the presence of the invisible Rontgen rays are (1) by its 
physical effects, i. e., the ability of these rays to produce a fluorescence 
from certain substances ; (2) by the chemical effects taking place 011 the 
sensitive plate. 

For making fluoroscopic examinations we may employ either the 
fluorescent screen or the closed fluoroscope. A cryptoscope has been 
brought into the market which allows of the detachment of the screen 
from the hood, Fig. 104, thus permitting of the use of the former 
without the cumbersome attachment. 

A. METHODS OF EXAMINATION. 

(a) Screen Examinations. By daylight the fluorescence of the screen 
is wholly imperceptible. Hence the necessity of excluding any light 
that might fall upon the screen and the eyes of the examiner. 

The brilliant fluorescence becomes manifest only in a darkened 
room, and, therefore, as in Rontgen' s original experiment, in order to 
exclude this extra light the tube should be covered with some dark 
material. 

The examiner holds the open screen in his hands, shifting it to the 
part desired, or it may be clasped to an adjustable rod attached to a frame 
which rests upon the floor. When the open screen is used, it should be 
brought as close as possible against the part under examination, so as to 
bring out the shadows more distinctly. 

Prior to covering the tube, it must be placed in its proper position, 
preferably with the platinum anode pointing toward the operator; the 
patient is then placed in front of the excited tube. (The cryptoscope is 
used in a lighted room.) In order to make a thorough examination the 
examiner's eyes must get accustomed to the darkened condition of the 
interior of this apparatus. When used on a sunny day, only the dark 
contour of the part under examination is first seen, gradually giving way 
to the more distinct details. Long and frequent examinations by this 
200 



THE PRINCIPLES OF TECHXIC. 



201 



means tire the eyes, often producing conjunctivitis among operators. 
For superficial and preliminary examinations this appliance is indispen- 
sable, but for deep examinations the open screen and dark room, with the 
tube's phosphorescence shielded, are to be recommended. 




FIG. 104. Detachable fluoroscope and screen. 

With a cryptoscope only one person is enabled to view the images 
cast upon the screen. When the screen alone is employed a group of 
persons can see the existing conditions, hence, the latter' s value for 
demonstrative purposes. 

(b) Preparation of the Patient. Always remove the clothing of the 
patient from the part which is to be examined, permitting in some 
instances the retention of the under garment, which should, however, 
always be free from wrinkles. Pins, buttons, and any other metallic 
structures which would cast shadows upon the screen must be removed, 
to prevent an incorrect diagnosis. 

In surgical cases where fine detail work is demanded, it is necessary 
to remove all the garments from the part to be examined, also splints, 
bandages, and powder dressings, as acetanilid, iodoform, boric acid, and 
plaster of Paris, all of which produce shadows upon the screen. The 
retention of wooden splints, though offering little or no obstruction to the 
rays, interferes with a thorough examination of a part on account of the 
immobilization of the joints, the ends of fractured bones, etc. These 
splints act as stays and do not permit of any movement of the part or 
of the close approximation of the screen. 



202 



ELECTRO-THERAPEUTICS. 



(c) Position of the Tube. The tube should* be carefully clamped into 
the notch of the holder so that the platiuum anode points to the screen's 
centre, causing it to fluoresce equally. The rays should pass in a straight 
line and not obliquely from the tube to the object. When examining the 





inimiiiiiiiiiiiH' minium^ / 
,' i* 
3 4 



FIG. 105. A STUDY IN SHADOW DISTORTIONS ( FLUOROSCOPIC OR SKIAGRAPHIC) WITH CORRE- 
SPONDING DENSITY DIFFERENCE. A, Anode parallel with the photographic plate. B, Axis of the tube 
parallel with the plate. C, Tube midway between the above positions. 

1, Either position of the object will throw the same shadow; the darker portion indicates the 
denser portion, whether the vertex is up or down. 2, Shadow smaller and denser. 3, Same object 
si ightly enlarged. 4, Cylinder or bone. Shadow denser at the extremities, because the rays must trav- 
erse more substance at those positions. 5, Metallic cylinder. To ascertain the perpendicularity of the 
rays, cross wires are placed upon both ends, when the shadows of the latter will superimpose on the 
plate or fluoroscope. If these shadows do not superimpose, the rays are taking an oblique course. 
6, Penny on its edge. The shadow line is dense, as the rays traverse much substance. 7, Surface vu-w 
of the same. 8, Fracture of two bones. The shadows, being superimposed, cast a very dense shadow. 
9, Rays traverse through less substance when the bones are longitudinally arranged, and cast less dense 
and separate shadows. 

thorax, for example, the tube should be so positioned as to cause the rays 
to fall perpendicularly upon the screen. When examining a field near 
the first, it is advisable to have the tube remain stationary, and to move 
the patient as necessary. 

Experience alone will guide the beginner as to the distance most suit- 
able for producing the best images upon the screen. For fluoroscopic 



THE PEI^CIPLES OF TECHNIC. 203 

work the patient is usually brought closer to the tube than when a skia- 
gram is taken. The shadows on the screen may often be sharply brought 
out by a careful and systematic adjustment of the distance between the 
patient and the tube. 

(d) Position of Patient. The patient may be examined by means of 
the fluoroscope in the lying, sitting, or standing positions. 

(e) Size, Shape, and Intensity of Image on the Screen. The X-rays 
diverge as they are projected from the anode. The shadow thrown on 
the screen, therefore, will be larger than the object itself. If the object 
is brought closer to the tube the distortion in size will be increased. The 
further the fluoroscope is separated from the object, the larger but less 
definite will be the shadow cast. If the rays do not fall perpendicularly, 
the shadow on the screen will be distorted. This can be well illustrated 
by the following experiment. (Fig. 105.) 

Take a lighted candle and hold it fifteen or twenty inches (38 or 51 
cm. ) from a white surface ; between it and the caudle place a coin. Upon 
moving the coin toward the white surface, its shadow becomes smaller 
and smaller as it is gradually made to approach that surface. The re- 
verse occurs when the coin is moved from the white surface toward the 
candle. Upon altering the plane of the coin a shadow of different shape 
is produced. When the rays fall perpendicularly on the surface of the 
coin, the shadow produced will be circular, but when tilted so that the 
rays strike in an oblique direction, the shadow cast will be elliptical. 
The change in size and shape of the shadow can be accomplished by al- 
tering the position either of the source of light or of the object. These 
principles are equally true in fluoroscopy and skiagraphy. 

The intensity of the shadow on the screen, even of the same kind of 
structure, will vary in different individuals. Thus the shadow of the 
adult male thorax will be darker than that given by a child's thorax. 
This difference in intensity depends upon the degree of penetrability of 
the rays, the distance of the tube from the fluoroscope, and the relative 
thickness of the part. 

The operator should be thoroughly conversant with the normal ap- 
pearance of the parts, so that he can use this knowledge as a standard of 
comparison for the corresponding affected part in the same individual. 

B. ADVANTAGES OF FLUOEOSCOPY. 

The method of using the fluoroscope is simple, inexpensive, and 
rapid, and allows of immediate comparison with the corresponding nor- 
mal part. The mobility brought about in the structure under examina- 
tion permits of its study in different positions. In examining certain 
parts that are in constant motion, as the heart, diaphragm, and thorax, 
a study can be made of any abnormality in their movements. 



204 BLECTEO-THEEAPEUTICS. 

C. DISADVANTAGES OF FLUOBOSCOPY. 

One of the limitations of this method is that the record is not perma- 
nent, although ' ' tracings ' ' can be made. In prolonged exposures for 
examinations the patient is liable to be "burnt," and the same injury 
may befall the operator's hands and eyes; for this reason, I at present 
never employ the fluoroscope, having discarded its use five years ago. 
Thicker parts, as the adult abdomen, the hip, and the skull, do not per- 
mit of satisfactory examination by this method. The same is true of 
certain fractures which present no displacement of the fragments (fissured 
fractures), also in detecting and locating small foreign bodies. As the 
soft structures present varying degrees of density, the presence of diseased 
bone, tumors of muscles or of the brain, etc., cannot be differentiated, 
owing to the affected tissue having only a slightly different density from 
that of the surrounding normal parts. As the penetrability of the rays 
cannot be controlled, and the varying degrees of density confuse the eye, 
the differentiation by means of the fluoroscope becomes at once most 
difficult and unsatisfactory. 

II. Skiagraphy. 

A. SYNONYMS, DEFINITION, AND NOMENCLATURE. 

Skiagraphy (Eontography, Shadowgraphy, Ixography, Electro- 
graphy, Skotography, Kathography, Fluorography, Actinography, Eadio- 
graphy, Diagraphy, Skiography, Pyknoscopy, New Photography, and 
Electro -Skiagraphy) is the art of photographing shadows on sensitive 
plates by means of transmitted light. The Eontgen Congress in Berlin 
on May 2, 1905, adopted a uniform nomenclature for the use of the Con- 
gress and for expression in writing. The following terms will be used 
in the future: Eontgenology, Bontgenoscopy, Bontgenography, Eout- 
genogram (Eontgen negative, Eontgen positive, Eontgen diapositive), 
Ortho- Eontgenography, Boutgentherapy, Bontgenizing. I present this 
new nomenclature, but I can hardly endorse it. I believe that the word 
"skiagraph" and its modifications are more easily pronounced, more 
general, and more euphonious. 

The differentiation between an ordinary photograph and a skiagraph 
is as follows : A photograph is an image produced on a sensitive plate 
in a camera by ordinary light, reflected from the surface of the object, 
converging and passing through a lens or pin-hole and then diverging 
and falling, thus producing a reduced size of the image on the plate. 
Therefore, a photograph is a "reflected" picture, and we see only that 
part of the object that is near or toward the optical perimeter when the 
object is opaque ; if transparent, the refraction obscures the clearness of 
the farther side. 



PHILADELPHIA HOSPITAL 

RONTGEN RAY LABORATORY, RECORD OF DIAGNOSIS. 



No. 



1 


NAME 


ADDRESS Nativity Month Day jgQ 


Occupation 


2 


SEX Male tingle 


Color Weight Ibs. Department Referred by M.D. 


Female Married 


Height Ward Address 


3 


Previous History 






4 


Date, Place, 
Duration, Character, etc., 
of Injury or Disease. 








5 


1'art or Organ Involved 




6 

7 


Physical 
and 
Clinical 








8 


Chemical and Microscopical 
Exam nations 






9 


REMARKS 



Technic Employed in Diagnosis. 


Diagnosis made from Skiagram or Fluoroscope 
or Stereo-Skiagraph 


I 

APPARATUS 


II 

POSITIONS OF THE TUBE 
AND PATIENT 


Ill 

QUALITIES OF THE RATS, 
TIME OF EXPOSURE 






A 



1 


Varieties and Make 


Distance of Anode 
from Plate 


Current going to the 
Primary Coil 








inch cm. 


Volts Amp. 


Revolving Plates 


Number 


Thickness of the Part 


Secondary or Induced 
Current 




inch cm. 




POSITIONS OF PART 


Parallel Spark-gap 




Rev. per Minute 


inch cm. 




Length of Spark-gap 


Antero-posterior 


No.ofBenoisfsScale 




inch cm. 


Lateral 


Degree of Vacuum of 
Tube: Low (soft). 
Medium, High (hard) 


B 


Accumulator Volts 


Flexion 




Extension 


Time of Exposure 


OF CURRENTS 


Ampere-hour 


Dorsal Decubitus 


sec. min. 




Direct Current 


Altern. Current 




Intensifying Screen 




Transformer 


Recumbent 


Variety of the Plate 


C 


Varieties 


Semi-recumbent 


Sizes Nos. Parts 




Sitting 


X A 


* 




Standing 


X B 






inch | cm. 


With or without 
Bandage. Splint, Cast 


X C 


OPERATOR 


Negatives 


D 

1 


Varieties 


E Varieties 


Over or under-exposed 
or developed, Patient 
moved 









No. of I nterruptions 


Non-Regulating 


No. of Prints 




Per Minute 


Self-Regulating 


Duplicate 


AUTOPSY 


Mechanical 


Osmo-Regulat. 




Mercury 






Wehnelt 




Caldwell 


Simon 





Diagnosis made by Director. M.D. 

or Assistant M.D. 

205 



206 ELECTEO-THEEAPEUTICS. 

In skiagraphy the X-rays emanate from a small point (1 mm. anode), 
diverge and pass through bodies opaque to ordinary light, throwing a 
relative shadow of the object on a sensitive photographic plate, producing 
merely an actual silhouette. The skiagraph, therefore, is produced by 
transmitted light. 

Before taking a skiagram, determine the best possible position that 
can be secured, by first employing the fluoroscope, and then substituting 
for it the sensitive photographic plate. On the latter the image cast will 
appear reversed, i.e., the bones will appear white and the surrounding 
soft structures darker, due to the fact that in the bones more rays will be 
absorbed, fewer penetrate, and hence there will be decreased oxidation on 
the photographic plate. When a photographic print is made from this 
negative, the appearance will be identical with the fluoroscopic image. 
(Hereafter the term skiagraph or skiagram will be used for the printed 
positive, and the developed sensitive (photographic) plate will be termed 
the negative.) 

B. THE PATIENT. 

History Taking. It is advisable to take complete histories of all cases. 
I employ the accompanying blank in book-form in the Philadelphia 
Hospital and in private work. Its main features are, the history of the 
case and the technic employed in each instance. 

Preparation of the Patient. Expose the part to be skiagraphed by 
removing the clothing. If the part is an extremity, have it totally bared. 
When examining the chest or abdomen, should the patient be chilly or 
complain of the unpleasant sensation caused by the plate, or be abashed 
at the thought of completely disrobing, the wearing of an undergarment 
may be permitted, or the part may be covered by a sheet of white linen, 
care being taken to remove buttons and pins, and not permitting any 
wrinkles or creases to exist in the field to be examined. If a part of the 
forearm or leg is to be examined for fracture, dislocation, etc. , splints and 
dressings of iodoform, boric acid, bismuth subnitrate, lead water and 
laudanum, etc. , must all be removed and the part skiagraphed in a bared 
condition. If a compound fracture is examined, avoid infection by 
covering with a thin sterilized gauze. In examining the abdomen, a 
purgative should be administered ten or twelve hours prior to the exami- 
nation. The patient must not be permitted to indulge in eating solid food 
previous to the examination. The urinary bladder should be emptied be- 
fore being skiagraphed, for calculi, and a rectal enema given. The walls 
of the stomach may be readily outlined by having the patient ingest large 
doses of bismuth subnitrate prior to the examination. 

Position of Patient. The patient should be placed in a comfortable 
position. It is sometimes not possible to do this, hence the necessity of 



THE PRINCIPLES OF TECHNIC. 207 

conducting the examination rapidly, but without sacrificing the results 
desired. In order to ascertain the necessary position for the patient to 
occupy first examine with the fluoroscope. 

The patient may assume various positions in skiagraphic work, 
which will be dealt with under the various clinical conditions. They 
are : the erect or sitting, anterior, posterior, or lateral, recumbent, dorsal 
decubitus and ventral, named after the position or view of the part that 
is in contact with the sensitive plate or fluoroscope. 

Immobilization of the Part. To obtain the sharpest outlines on the 
plate, the patient must not be permitted to move while under examination, 
or failure will be the inevitable result. Those that are timid should be 
previously instructed to ignore noises, flashes, etc., necessarily occurring 
during the examination. It is better for the skiagrapher to have an 
under-exposed plate rather than one that is blurred. This blurring may 
be independent of the patient, and be caused by the shaking of the tube 
or the table, or of both. 

The part to be examined may be held in one position by firmly 
strapping it to the table, although I seldom find this necessary. In cer- 
tain cases, as in fractures, where there is movement of the part (the result 
of muscular spasm), the annoying symptom may be met by steadying 
the limb with sand-bags, etc. When it is found impossible to keep 
children and the insane under control, resort must be had to hypodermic 
injections, or to the administration of an anaesthetic. 

C. PLATES, THEIR PREPARATION, SIZE, AND PROTECTION. 

The plates as sent by the maker are not ready for use ; hence it 
becomes necessary to assort and arrange them in a dark room, so that 
they may be conveniently handled by the examiner. Place the plate in 
a black paper envelope, which in turn is covered by a heavy yellow one ; 
this prevents injury by light, though it will be affected by the X-rays 
with as great ease as desired. The size of the plate depends upon the 
dimensions of the part to be skiagraphed ; those that I usually employ 
are one size larger than is absolutely necessary. The plate should be 
protected against breakage, damage from perspiration or other excretions 
of the body, and from heat. To insure against breakage, it should be 
placed over a smooth board, as I find that a plate-holder is objection- 
able in preventing the approximation of the plate close enough to the 
part to be examined, thus preventing sharp definition of shadows. 
Between the patient and the plate I introduce a blotter or a sheet of 
aluminium, oiled silk, or celluloid, which prevents injury from sweat, 
urine, etc. For the sake of comparison, it is a wise provision to have the 
plate large enough to take both sides of the body (hips, shoulders, etc. ). 
For this purpose, place the tube in the median line of the body and take 



208 ELECTBO-THEBAPEUTICS. 

both sides with one exposure. This obviates the error that would result 
if the two sides were taken separately, when in all probability the posi- 
tions would be different. Where the plate cannot be brought in contact 
with the part, owing to a curvature of the latter, as on the flexor or 
extensor surfaces of the elbow, or on the spine, in common with others, 
I at times resort to the use of a film. The plate should be placed against 
or under the part examined, with the gelatine side up. The part should 
be as nearly centralized on the plate as possible, so as to get the import- 
ant outlining shadows directly in the centre of the plate. Eays should 
fall as nearly perpendicular as possible. 

Data on the Negative. It is always advisable that the plate should be 
marked so as to guard against errors. The method of plate- marking 
that I employ consists in placing lead letters and numbers in reverse type 
in the corner of the plate, designating the part examined, the date, 
the name of the operator, and also the name of the institution. The 
letters and numbers employed for this purpose should be small, so as to 
not occupy too much space on the plate. When exposing a part I 
usually indicate on the plate whether "right" (B) or "left" (L). 
When making more than one exposure of the same part, I usually 
indicate the number of separate exposures consecutively by placing 
on the plate the lead letters, A, B, and C. In medico-legal cases an 
identifying mark is most important. 

D. SELECTION AND USE OF THE CROOKES TUBE. 

The Crookes tube must be selected according to the requirements of 
the case. Thus, the "hard" tube, which produces a greater degree of 
penetrability of the rays, is adapted for the thicker parts, in detecting 
the larger foreign bodies, and in taking a negative of a fracture through 
a plaster cast. In making skiagraphs of children, where their move- 
ments would ordinarily blur the negative, the short exposure required by 
this variety of tube is a marked advantage. 

When soft tissue differentiation is to be brought out, as in skia- 
graphing a muscle tumor, a cyst, a small foreign body, or a tuberculous 
focus in bone, resort must be made to "medium " or even " hard " tubes. 

The consensus of opinion among the profession is that a soft tube is 
desirable for skiagraphing soft tissues in order to obtain a clear tissue 
differentiation. But I have abundantly proved that with a hard tube, a 
short exposure, and proper development, the same end may be attained. 
The advantages of the latter method are : The time of exposure being 
brief, the liability of movement of the patient is minimized and there is 
less liability of penetration than with a soft tube of a longer exposure. 

Position of the Tithe. Some investigators claim that no X-rays 
are produced back of the anode, others assert that they do exist in this 



THE PEINCIPLES OF TECHNIC. 209 

position but possess very little penetrating power. As to whether the rays 
are uniform in penetration in the active hemisphere, or if they possess a 
point of maximum intensity, is another disputed question. Buguet and 
Londe assert that the intensity of the rays varies at the active hemisphere 
in different tubes, and in different kinds of the same tube. In some 
tubes the most effective X-rays are evolved at right angles to the axis of 
the tube ; in which case the latter must be placed parallel to the object 
to be skiagraphed. In other tubes the zone of greatest intensity is at a 
right angle to the plane of the anode, when the auodal surface should be 
in the centre and parallel to the object under examination. I prefer a 
position intermediate between these two. (See Fig. 105, C.) 

M. Bordier 1 says: "The direction of this principal axis, along 
which the Bontgen effects are at a maximum, must be determined sepa- 
rately for each focus-tube, and it evidently lies in the median plane, i. e. 
in the plane passing through the centre of the cathode and perpendicular 
to the auti- cathode." 

He placed a series of pastilles in an arc, having for a centre the 
focus of the anti-cathode ; the direction of the principal axis was given 
by the pastille which was most discolored. 

In experiments on three Miiller tubes tested in this way it was 
found that the principal axis made an angle of 70 with the line passing 
through the centres of the cathode and the anti- cathode. 

Form of the Say -emitting Area of the Anti-cathode. Gocht, 2 in experi- 
menting with a pin-hole camera, succeeded in photographing a luminous 
area on the surface of the anti-cathode, the ray-emitting area having a 
pyriform- ovoid shape. He asserts that the angle between the plate and 
the anti-cathode at which the spot of light is most circular and there is 
least penumbra is not 45, but nearly 65. 

Direction of the Eays. Bays emanating from Crookes tube should 
fall perpendicularly. To prove this, place a metallic cylinder, 3 or 4 
inches long, over the plate or on the screen. If the rays are perpen- 
dicular the shadow cast will be circular ; if the rays are proceeding in 
an oblique direction, the shadow will be elliptical or the shadows of two 
cross wires on both the ends will not be superimposed. (See Fig. 105, 5.) 

Distance of the Tube from the Plate. The thicker the part and the 
greater the extent in area to be skiagraphed, the greater should be the 
distance between the tube and the object. This distance must be 
measured from the anode to the plate, and is usually about 20-24 inches 
(50 or 60 centimetres). Where any movement of the part is likely, it 
is preferable to place the tube closer, in order to reduce the time of 
exposure. 

1 Archives of the Rontgen Ray, June, 1906, p. 7. 
1 Ibid., April, 1906, p. 312. 

14 



210 ELECTRO-THERAPEUTICS. 

E. FACTORS VARYING THE TIME OF EXPOSURE. 

This is most important ; no definite rule can be formulated relative 
to the standardization of any unit of time. The time of exposure varies 
under the following conditions : 

1. The capacity of the apparatus and the penetrability of the rays. 

2. The peculiarity of the part to be examined. 

Under the first heading we must consider the size and make of the 
apparatus. If the static machine is used, we must take into account the 
number and size of the plates and the rapidity of the revolutions per 
minute. In the use of the coil account must be taken of its size, and the 
variety of the interrupter, with its frequency of interruptions, etc. 

Under the secondary heading we consider the thickness of the part 
and its texture. The thicker the part, the more prolonged must be the 
exposure ; nevertheless, while the chest is as thick as the abdomen, the 
latter requires a longer exposure, because the former is more easily pene- 
trated by the rays, due to the contained air. 

Quality of the Rays. Rays of high degree of penetrability will require 
a shorter time of exposure, and conversely with rays of medium and low 
degrees of penetration. The sensitiveness and variety of the plate play 
a minor part in the time of exposure. N"o plate has thus far been found 
that is specially sensitive to the X-rays only. 

Intensifying Screens. Intensifying screens are intended to shorten the 
time of exposure by placing in contact with the photographic plate a 
screen of fluorescent substance, the latter acting like ordinary light on the 
sensitive plate. It must be borne in mind, that the granularity of the 
fluorescing surface reduces the definition of the skiagram, at the same 
time omitting details of the smaller bony structures, and the necessity 
of either using color-sensitive (ortho-chromatic) plates, or first color- 
sensitizing ordinary plates, since the best screen (platiuo-cyanide of 
barium) fluoresces with a yellowish-green light which does not greatly 
affect ordinary dry plates. 

I have conducted experiments that lead me to the belief that the ratio 
of exposure necessary with an intensifying screen to the time required 
without the screen is as 1 to 5 or 6. This screen will markedly assist in 
the reduction of the time of exposure in fractures and the presence of 
foreign bodies about the thicker structures, such as the hip, the pelvis, 
and the abdomen. Of course by this procedure we sacrifice the fine de- 
tails of the softer structures, and for this reason I have abandoned its use. 

F. PREVENTION OF SECONDARY OR SAGNAC RAYS. 

When the Rontgen rays penetrate bodies, the so-called secondary 
rays of Sagnac are produced in the tissues. The rays being primary, 
the secondary rays will in turn produce rays called the tertiary. 



THE PRINCIPLES OF TECHNIC. 211 

This diffusion or production of secondary and tertiary rays will be 
increased when the time of exposure is increased and when the part ex- 
amined is of considerable thickness. In order to prevent these useless 
rays, which so often cause a foggy appearance on the negative, many 
devices have been suggested, principal among which are the following : 

The Lead Iris Diaphragm. By the method of Albers-Schonberg, 
i. e.j by means of the compression diaphragm (Fig. 99), the pri- 
mary rays are largely cut off, with a consequent lessening of the sec- 
ondary rays. The irradiated area is diminished in size, and the 
depth of the parts is likewise decreased, through the pressure exerted by 
the compressing action of the diaphragm. 

Robinson, in Holzknecht's laboratory, modifies the above by pressing 
upon certain parts of the diaphragm with specially devised metallic rods, 
in order to make the diaphragm conform to uneven surfaces, such as the 
ankle, foot, knee, etc. 

I have seen Coutrenioulins, of Paris, applying lead plates against 
the flanks and chests of patients, to prevent the disappearance of the 
shadows of soft tissues. He demonstrated the value of this method by 
employing these plates on one side only. The development of the 
negative showed in detail the shadows of the soft parts, while on that 
side where no lead plate was applied the shadows of the soft parts were 
invisible. 

III. Photography. 

The photographic processes involved in the production of a nega- 
tive from a plate that has been exposed to the X-rays do not differ from 
those involved in making ordinary photographic negatives. Experience 
in this branch of X-ray diagnosis is absolutely necessary, hence steady 
and continuous work is essential, in order to become familiar with the 
many intricate points which so frequently arise. 

Dark Room. The dark room must be absolutely free from ordinary 
light and so constructed as to allow of ready ventilation. Both of these 
requirements may be met by utilizing a zig-zag entrance. The room 
should contain trays, graduates, faucets (for hot and cold water), and a 
suitable box or tank, encasing vertical grooves, for the purpose of ' i fix- 
ing . ' ' As the process of developing, which we shall presently describe, 
produces a staining of the hands, and sometimes a dermatitis from the 
action of metol, the use of rubber gloves is desirable. After employing 
them for a short while, the operator becomes accustomed to them. When 
the developing is completed, they should be thoroughly rinsed in water 
and hung up to dry. 

Light. When developing, advantage may be taken of the ruby lan r 
tern or incandescent lamp, properly shielded. Daylight, on account of 



212 ELECTRO-THERAPEUTICS. 

its variability, is unsuited for the purpose. In brief, the room should 
be glazed with a sash composed of ground glass, a yellow and a ruby 
glass, and a shade or curtain of a dark color. 

Sensitive Plates and Films. Skiagraphs are easily projected on photo- 
graphic glass plates, papers, or films. Wet or collodion plates are only 
slightly affected by the X-rays. Great advantage is secured by employ- 
ing double emulsified plates, the depths and contrasts of the images being 
brought out more thoroughly. The X-ray plate, which is always to be 
preferred to the ordinary plate, should be employed. 

Owing to their flexibility, celluloid films can be brought in contact 
with any uneven part of the body. But if not handled with scrupulous 
care, the emulsion is liable to crumble. Other objections are their cost, 
their constantly varying sensitiveness, and the fact that they are not easy 
to manipulate. 

The double-coated celluloid films are coated singly on each side, 
causing a reduction in time to the exposure of the rays ; but they offer 
difficulties in development and by transmitted light present the blurred 
effect of both films. Both paper and celluloid films may be superim- 
posed so that half a dozen or more may be simultaneously exposed to the 
rays. Bromide paper can be examined only by reflected light. This 
paper is cheap and does not necessitate first, producing a negative ; its 
use is not to be recommended, as a good picture never results thereby. 

Care of the Plates. Because of the extreme sensitiveness of the 
plates, they should be stored in places that are absolutely free from 
smoke, gases, excessive light, etc. The temperature of the room should be 
constant, sudden changes being liable to cause a condensation of moist- 
ure upon the coated side which in time results in u mildew fogging." 
The plate packages or boxes should be placed on their edges, thus avoid- 
ing undue pressure on the individual plates. As to the number of plates 
to be kept on hand, I recommend not more than a mouth's supply, the 
operator, of course, must be governed by the amount of work he is doing. 
The plates should not be unpacked from the maker's cases and placed in 
the regular X-ray envelopes until needed, this precaution guards against 
fogging of the plate. If the plates are to be stored in the laboratory 
where the X-ray apparatus is located, a wooden closet, carefully lined 
with sheets of lead, should be built, to avoid the damaging effects of the 
rays upon the plates. If stock plates are stored in an adjoining room, 
they should be protected against the rays in exactly the same manner. 

A. DEVELOPERS. 

A developer consists of four parts, (a) reducer, (6) preservative, 
(c) accelerator, and (d) a restrainer. 

(a) Reducers. The best reducing agents are metol, pyrogallol, 



THE PRINCIPLES OF TECHNIC. 213 

eikonogen, hydrochinone, and rodinal. They all undergo easy oxida- 
tion ; hence sodium sulphite is added as a (b) preservative. Combinations 
of the above are usually preferred. Regulate the action of the developer 
by the addition of an accelerator or a restrainer. If the reducer acts 
tardily, add the accelerator (carbonate of sodium or potassium). Too 
rapid developing with strong solutions is undesirable ; it means lack of 
gradation, a forcing up of the high lights before the developer has had 
time to act on the less exposed parts of the plate. Ready prepared de- 
velopers will not be suitable for skiagraphic plates. It should be remem- 
bered that the operator should adhere to one kind of developer and 
become thoroughly acquainted with its action. The following are the 
formulae that I daily employ in my laboratory : 

Water 100 ounces (3000 c. c.) 

Metol 120 grains (8 grams.) 

Hydrochinone 100 grains (6.6 grams. ) 

Sod. sulphite (crystals) 4 ounces. (120 grams.) 

or 

Water 64 oz. (1920 c. c.) 

Eikonogen 1 oz. (30 grams.) 

Hydrochinone . . . .' | oz. (4 grams.) 

Sod. sulphite (crystals) 2% oz. (75 grams.) 

(c) Accelerator. With either of these reducing solutions, it is neces- 
sary to employ, in conjunction, an accelerating solution, made up as 
follows : 

Water 64 oz. (1920 c. c.) 

Potass, carb. (crystals) 8 oz. (240 grams.) 

Sod. sulphite (crystals) 2 oz. (60 grams.) 

The dry or anhydrous chemicals are about twice as strong as the 
crystals, and vice versa. 

Combinations of hydrochinone with metol when too old should not 
be used, as they would cause the negative to present a " streaky" or 
" blotchy" appearance. 

The one solution developer of rodinal is convenient and effi- 
cient, especially when employed for two-sided films or plates. This 
agent keeps well as long as the containers are kept filled and tightly 
corked. 

With its use the image appears quite rapidly, but development 
must be continued until the film is so dense that no details are discern- 
ible when viewed by transmitted light. The following formula may also 
be employed : 

Rodinal 1 part. 

Water 20 to 40 parts. 



214 ELECTRO-THERAPEUTICS. 

An advantage of the ortol developer is that it may be repeatedly 
used, keeping perfectly well as long as the stock solution is kept in 
small bottles and tightly corked. Formula : 

Water 60 oz. (1800 c. c.) 

Ortol J oz. (20 grains. ) 

Potass, bromide 20 grains (1.3 grams.) 

Sulphite of soda (crystals) 6 oz. (180 grams.) 

Carbonate of soda (crystals) 5 oz. (150 grams.) 

For use : Dilute one part of the above with two to four parts of 
water, according to the density desired. 

(d) Restraining Solution. Ten per cent, solution of potassium bro- 
mide kept in a tightly corked bottle. (Pipette and dropper are useful 
adjuncts in the handling of this solution.) 

Tropical Developer. For hot climates where no ice is available. 

Water 50 ounces ( 1500 c. c. ) 

Sulphite of soda (crystals) . 2 ounces (60 grams.) 

Bromide of potassium 20 grains (1.3 grams.) 

Citric acid 20 grains (1.3 grams. ) 

For use : To 4 oz. of the above solution add 10 grains of dry amidol. 
Before developing place the plate in 

Water HO parts, 

Formalin 1 part, 

for about three minutes, rocking the tray occasionally, then rinse well 
and place in the developer. ' 

B. MODUS OPERANDI OF DEVELOPMENT. 

After the plate has been properly exposed it is taken to the dark 
room, the envelope opened, and the plate removed. (After having been 
exposed, it should not be allowed to remain in the exposing room, if an- 
other case is to be skiagraphed. ) Place the plate, gelatine side up, in a 
tray of sufficient size, and pour on the developer. For development of 

1 Henry Hulst (Transactions of the American Rontgen Ray Society, 1905) says : 
"The developer which I use for exposures of one second or less in chest work, I use 
for calculi as well. It is as follows : 

Potassium carbonate, dry 12 dr. (48 gin.) 

Sodium sulphite, dry 6 dr. (24 gm.) 

Potassium bromide (10 per cent, sol.) 2 oz. (59.2 c. c.) 

Hydrochinone 4 dr. (16 gm.) 

Water 1 qt. (1 litre.) 

" If the high lights begin to show before 40 seconds, from two to four ounces 
more of the potassium bromide solution are added. Development should be complete 
in four minutes." 



THE PRINCIPLES OF TECHNIC. 215 

the plate, take four (4) parts of either reducing agent, above mentioned, 
and about one-half (^) part of the accelerator solution. If the image 
does not appear in half a minute, add another portion of the accelerator. 
Thus cautiously add at very brief intervals small quantities of the accel- 
erator, and the image will be better evolved than if an excess of the 
alkali be added to the reducer at first. Start at one corner, and with a 
single sweep, pour on sufficient solution, rocking the tray to secure 
thorough immersion and evenness. To splash the solution is to produce 
air bubbles, and the latter will form spots on the negative. Should 
air bubbles be detected, touch them lightly with a pledget of cotton. 

For development of a special make of plate, follow the directions 
on the box. Observe all changes going on in the plate. After the plate 
has been developing for a minute or longer, lift it from the tray and ex- 
amine it by transmitted light to see how far the process of development 
has advanced. This is dependent upon the time the sensitive plate was 
primarily exposed to the action of the rays, to the thickness of the part 
under examination, the type of plate, and also upon the temperature of 
the developer and the dark room. I always judge the density by trans- 
mitted light, deeming this preferable to the reflected picture from the 
sensitive side. Another method is the appearance of the picture on the 
glass side or back, showing the reduced metallic silver deposited on the 
glass. It will take a longer time to develop a plate of the lungs, pelvis, 
abdomen, or the denser parts of the body than it does of the hand or foot. 
For the former structures keep the plate in the developer until the whole 
surface is uniformly blackened and very little light is transmitted. In the 
fixing bath the proper degree of density will be produced. To strongly 
contrast the bony and fleshy structures of a part, reduce the time of de- 
velopment or dilute the developer; the result will be a "soft negative.' 7 
The necessary density may be obtained later by intensification. For a 
good negative, start with weak developers and gradually increase the 
strength by adding stock solutions (the reducer). In order to bring out 
the details with greater delicacy, some prefer to use first a suitable 
hydrochinone developer, to effect sufficient density, and then transfer the 
plate in rodinal or metol developers. When the plate is sufficiently de- 
veloped, put it in a trough of running water or under a stream from a 
spigot, always seeing that the gelatine side is up, and that it is not liable 
to get scratched by any contact with the spigot or other body. Continue 
the washing for at least two minutes. 

The denser the structure, the less will be the oxidation of the emul- 
sions, and consequently the later the appearance of the part on the plate. 
If structures of different densities appear simultaneously on the plate, it 
signifies over exposure ; in that case, pour off the developer, and substi- 
tute a fresh, weak developer. It should be remarked that the developer 



216 ELECTRO-THERAPEUTICS. 

must not be diluted, as it makes development slow, and the negative will 
be soft ; this is especially true of the thick parts ; instead put in less of 
the accelerator (sodium carbonate). During the summer, put ice into 
the developer, or put the developing pan into a tray of ice- water. Tem- 
perature of the developer should be 65 or 70 F. (18 to 21 C.). Over 
exposed plates should not be removed quickly from the tray, as the de- 
veloper will not have time to penetrate sufficiently deep to affect the lower 
layers of emulsion; although the upper layer by its darkening may 
deceive the operator. 

If the image appears slowly, i. e., within a minute or two, it sig- 
nifies under exposure; in this case tilt the solution to the corner of the 
tray, and add some of the accelerator. If after this addition and suffi- 
cient development, the desired density is not obtained, pour off and wash 
the plate, and employ a fresh developer. 

Of late years the "tank" or slow developing process, has been used 
by some skiagraphers. The tank development is to be recommended for 
plates which have not received full exposures and for the smaller size 
plates. It is claimed that the length of time to which the plate is sub- 
jected to comparatively weak developing solution (40 to 60 minutes), will 
bring out much more detail than the application at once of a more vigor- 
ous developer. However, for fully timed plates, I would prefer the 
methods recommended above. The following is Mr. Cramer's formula : 

STOCK SOLUTION. 

Water 32 oz. (1000 c. c.) 

Carbonate of soda (dry) 2 oz. (62 grams.) 

Sulphite of soda (dry) according to desired 

color of negative 1 to 1 J oz. (32^18 grams. ) 

Bromide of ammonium 30 grains. (2 grams. ) 

Citric acid 30 grains. (2 grams.) 

Hydrochinone 1 dram. (4 grams. ) 

Glycin 2 drams. (8 grams.) 

Metol 2 drams. (8 grams. ) 

Pyro 4 drams. (16 grams. ) 

Dissolve the chemicals in given rotation. 

To preserve the stock solution, we recommend filling small bottles 
of the exact size to hold just enough for making the diluted solution 
for the tank. The bottles should be quite full and tightly corked. 

FOR- USE : 

Water 120 ounces. 

Stock solution 6 ounces. 

The developer should be used fresh, and its temperature kept between 
60 and 65 F., until development is completed. 




FIG. 106. Envelo developer. (Lyon Camera Co.) 




FIG. 107. Automatic tray-rocker. (Rontgen Manufacturing Co.) 



THE PBINCIPLES OF TECHNIC. 217 

It is necessary to observe the following rules in handling the developer: 

No. 1. Immerse the plates in a tray of cool water before putting them 
in a tank. 

No. 2. Immediately after immersing the plates in the tank solution, 
move the plates up and down with a quick motion, to prevent air-bells or 
bubbles forming on the surface of the film. 

'No. 3. After the plates have been in the tank from five to ten 
minutes, lift each plate out of the tank and reverse its position^ by plac- 
ing that end of the plate which was at the top of the tank to the bottom . 
This will prevent the appearance of streaks, which are sometimes found 
in tank development. 

No. 4. It is well to rock or shake the tank, at least once in every five 
minutes, during development. This often prevents the appearance of 
streaks or spots in the negatives. 

The Envelo developer (Fig. 106) is an extremely simple device, 
designed to develop two plates at one time, by the tank or stand method. 
It is constructed of metal, heavily nickeled on the outside, and coated on 
the inside with a liquid proof composition. 

When the plates are large, and slow development is aimed at ; in 
order to save time, resort may be made to the tray-rocker (Fig. 107) 
which works automatically through the agency of an electric motor. 

Fixing. After development, the plate is washed in the tray with 
running water, instead of the usual method of washing it, when removed 
from the tray. This prevents breakage of the plate and likewise contact 
with the developer, which would cause irritation to the fingers. 

The process of fixing dissolves out all the silver bromide unacted 
upon by the light or developer. Allow the plates to remain in the fixing 
bath for three to five minutes, after the chemical agent has been com- 
pletely removed ; this will insure permanency, freedom from stains, and 
perfect hardening. After all "whiteness" has disappeared from the 
glass side, bring i l the negative ' ' to the light. Leave it five minutes longer 
in the solution, to allow for thorough fixing, as this plate has a thick 
double coated emulsion. 

The acid chrome fixing bath I largely employ, as it does not discolor 
and keeps longer than the plain hypo fixing solution. It is made as 
follows : 

Water 100 oz. (3000 c. c.) 

Sulphuric acid 3 oz. (90 c. c.) 

Sulphite of soda 4 oz. (120 grams.) 

When dissolved, add 

Hyposulphite of soda 2 Ibs. 

Dissolve, and add 

Chrome-alum, from one to two ounces, previously dissolved in 20 
ounces of water. Follow by adding water to make a total of 160 ounces. 



218 ELECTBO-THERAPEUTICS. 

In hospitals aud large laboratories it is useful to employ two large 
wooden boxes that act as tanks. (Fig. 108.) In the Philadelphia 
Hospital I have these boxes divided into different sized compartments 
to accommodate the various sized plates. Each compartment has six 
vertical grooves, for holding six plates. One of these tanks contains 
the acid hypo sufficient for six months' use. The other tank is similarly 
constructed, in which the water enters at the bottom and circulates 
to the top, and then overflows into a discharging pipe. 




FIG. 108. Author's washing tank. The fixing tank is similar in construction. 

Washing. After fixing, washing must be quickly and thoroughly 
done. One hour's washing with running water is sufficient ; if the sup- 
ply be not so accessible, place the negative in a flat dish and constantly 
rock for five or ten minutes. Change the water and repeat the process 
for one-half to three-quarters of an hour. Remove the negative, again 
wash under the spigot, using a pledget of cotton to wipe off any foreign 
particle adhering to the gelatine coating. 

Drying. Dry the negative in a room of moderate temperature, in 
which a ventilator supplies plenty of air. Do not dry in the sun, as 



THE PBINCIPLES OF TECHNIC. 219 

sunlight produces softeuiug and increases the density of the film. To 
dry a negative hurriedly, i. e., in five or ten minutes, lay it in a bath of 
alcohol after washing thoroughly, or put before an electric fan. 

The negative must be completely dried in one room. To take it par- 
tially dried into another room and there complete the process, will result 
in the finished negative offering a difference in densities. During the 
summer season the negative becomes denser than in winter. 

Hardening. After fixing the negative, wash and place it in the 
following : 

Water 4 ounces (120 c. c. ) 

Formaldehyde 1 ounce (30 c. c. ) ' 

Keep in this solution from five to ten minutes, rocking the tray from 
time to time. If the solution is made too strong the film may peel off. 
If hardening is done before the fixing, then the fixing process should 
require more than usual time. This will frequently be of necessity in hot 
climates and during the hot seasons in temperate climates. 

C. IMPROVEMENT OF THE NEGATIVE. 

Intensification. This process with proper exposure and development 
is seldom required, except for special purposes, i. e., for under exposed 
or under-developed plates. The negative is first well washed and then 
placed in the following : 

Mercuric bichloride 200 gr. (13.3 grams.) 

Potassium bromide 120 gr. (8.0 grams.) 

Water 6i oz. (200 c. c.) 

Keep the plate in this solution a short time, when it will be observed 
to be bleached uniformly white, assuming the appearance of a positive ; 
the longer the negative is bleached, the denser it will become. It is 
again thoroughly rinsed and washed under the spigot for at least a half 
hour in running water, and then blackened in the following solution : 

Sodium sulphite 1 oz. (30 grams.) 

Water 4 oz. (120 c. c.) 

or 

Ammonia 20 min. (1 c. c.) 

Water 1 oz. (30 c. c. ) 

It now being blackened, it is again washed, followed by drying. 
The least yellowish cast indicates that the negative has not been washed 
sufficiently after the bleaching. The prints of such negatives show the 
soft tissues very faintly, producing a great contrast, and on account 
of their great density they print very slowly. 



220 ELECTKO-THERAPEUTICS. 

General reduction is used when the negative is very dense, as a 
result of over exposure, over development, or where there is an excessive 
amount of alkali present in the developer. To correct this use the 
following solution : 

A. Water 16 oz. (500 c. c.) 

Hyposulphite of soda 1 oz. (30 grains.) 

B. Water 16 oz. (500 c. c.) 

Potass, ferricyanide 1 oz. (30 grams.) 

Mix 8 parts of solution "A" and one part of solution "B," and use in subdued 
daylight. 

The negative can be placed in this solution directly after fixing. 
If a dry negative is to be reduced, it must be soaked in water for at least 
half an hour, before applying the solution. To avoid streaks, always 
rinse the negative before holding it up for examination. As soon as 
sufficiently reduced, wash thoroughly. When not in use keep solution 
"B" protected against the action of light. 

A gradual uniform reduction will take place, its rapidity, of course, 
depending upon the quantity of potassium ferricyanide added. When 
sufficiently reduced, wash and thoroughly dry. To reduce locally, apply 
carefully with a brush or cotton some of the solution on the wet nega- 
tive, allowing it to remain until sufficiently reduced ; follow by thor- 
oughly washing and drying. 

The other reducing agent consists of persulphate of ammonia in 
water. One part to forty is strong enough for most purposes (^ oz. to 
10 ounces). This solution does not keep well, and should be made as 
required. Its action on the plate must be carefully watched it acts 
slowly in the beginning, and then all of a sudden very rapidly. After 
sufficient reduction, rinse thoroughly, and place in a 10 per cent, solution 
of sulphite of soda. Wash well again and dry. 

There is a great difference in the action of these two reducers. 
Potassium ferricyanide, like most reducers, attacks the fine details 
more readily than the denser parts, the negative becoming harder and 
thinner. The persulphate reducer, on the contrary, appears to reduce 
the denser parts more in proportion, so that the negative becomes 
slightly flatter. 

Local Reduction. This consists of bringing in contact with a certain 
part of the negative some reducing agent, destroying contrast to some 
extent. Let us suppose a negative having a printing effect of faintly 
bringing out the fleshy part and deeply the osseous part ; should we 
desire to bring out more heavily the fleshy part, we employ what is 
termed the local reducer. To place this only on the il fleshy" part of 
the negative requires a great deal of skill the effect being to further 



THE PRINCIPLES OF TECHNICS. 221 

reduce the silver salt, thus giving more chauce for the rays of light to 
penetrate the negative and printing the paper more heavily. The best 
results in local reduction can only be obtained by constant practice. In 
local reduction the plate must be previously wet, as otherwise a streaked 
appearance will result. 

Causes and Prevention of Faulty Negatives. Fogging. A total black- 
ening of the plate under development is distinguished from other 
types of fogging in that the former remains clear at its edge. Fog 
also results from a developer containing too much alkali, too high a 
temperature, or exposure to other rays than those emanating from 
the Grooves tube. Improper or too much light in the dark room also 
causes fogging. General fogging cannot be remedied ; the negative, 
however, may be sufficiently cleared by a reducer, followed by intensi- 
fication. 

Stains. Deep yellow, orange, or brown stains appearing gradually 
either in patches or all over the plate may result from imperfect fixing 
or incomplete washing after fixing. Another cause for these stains is 
decomposed hypo in the film by improper washing, or the use of alum 
or acids. Over developing frequently causes greenish stains (excess of 
reducing agent). 

Spots. Spots or pin-holes in negatives are usually due to air- 
"bubbles and decomposition of the films. Small clear spots generally 
result from dust particles. Another type of transparent spot, 
irregular in shape, results from the scum of the developer. This is only 
seen on the surface of very old developers. Sediment, accumulating in 
the trays, graduates, and solution bottles, may come in contact with 
the film, thus interfering with the action of the developer, the result 
being spots. Particles of undissolved developer (pyrogallol) adhering 
to the film produce irregular dark spots. Cleanliness in all the steps 
of the developing process is the only preventive against the formation 
of spots. 

D. PRINTING (POSITIVE), TONING, AND MOUNTING. 

The X-ray image of the negative may be printed on paper as in 
ordinary photography. All diagnoses, as far as practicable, should be 
made from readings from the negative instead of from the print. There 
are instances, however, where information may be gained from the print 
which inadvertently had been overlooked in the interpretation of the 
negative. Another advantage in using the print is that it may be passed 
among a class of students for study, a procedure that might endanger a 
valuable negative. A properly exposed and well developed negative 
usually serves to produce a good print on almost any reliable paper. The 
commonest printing-out paper used in this work is the ordinary 



222 ELECTRO-THERAPEUTICS. 

"albuma," the printing of which is conducted by sun-light. The 
advantage of this paper is that the strength of printing process may be 
easily controlled. 

"Dodging" is a method employed for reducing inequalities of a print 
from a good negative. We can best understand this method by citing an 
example. Let us take a negative of the hand ; it is placed in a regular 
printing frame as already referred to. We are all aware of the fact that 
the carpo-metacarpal part of the negative has been reduced by the devel- 
oper to a less extent than the phalangeal portion. Therefore in the print 
the former portion would be shown more strongly than the latter, because 
more rays can come in contact with the paper. In order to equalize the 
print, we "dodge" the carpo-metacarpal portion of the hand by con- 
stantly moving a piece of card-board above it, L e., we shield it against 
further action of the light rays. This permits of the phalaugeal portion 
being printed to the extent desired. Were we to cover the carpo-meta- 
carpal portion by laying card-board over it, without moving it, a divid- 
ing line would be readily discernible, being exactly the opposite of what 
we desire to achieve. 

Ground- Glass Substitute. The glass surface of the plate is cleaned of 
all dust particles, finger marks, etc., and a solution of certain gum resins 
in ether called ground-glass substitute is poured evenly over the surface, 
precaution being exercised to prevent the liquid from coming in contact 
with the film. The ether evaporates more rapidly, leaving behind an 
even coating of gum resin, which, adhering firmly, gives a ground glass 
appearance. The negative may now be " evened up'' by daubing burnt 
umber into the gum layer corresponding to those parts which are u thin.'' 
To even up a negative requires skill, and in order to guard against any 
errors I advise the use of a print from the negative before it has been 
prepared, thus acting as a guide. If the negative is uneven, scrape the 
ground-glass substitute from those parts that are too opaque to the rays. 
thus allowing of the easy passage of the latter. Soft negatives should be 
printed with tissue paper over the printing frame. With a little practice, 
the inexperienced will rapidly learn the art of developing. It is better 
that he do this work himself than to rely on the services of professional 
photographers. 

Developing Papers. Velox and bromide papers can only be printed 
in dark rooms by artificial light, the sensitized surface of the paper being 
placed against the gelatine side of the negative, and the printed image is 
brought out by a process of developing. The advantage of these papers is 
the rapidity with which the printing is done without the aid of sunlight. 
The time of exposure to artificial light can be ascertained only by follow 
ing the directions and by experience. Velox and bromide paper should be 
developed according to the " instructions " accompanying each package. 



THE PRINCIPLES OF TECHNIC. 223 

Toning Process. Albuma paper, after being printed, should be 
trimmed, and then washed in running water until it ceases to be " milky." 
The prints should now be placed face to back, one upon the other, and 
introduced into the toning solution. The lowest print is then removed 
and placed upon the uppermost, continuing this process for some time. 

TONING SOLUTION. 

Chloride of gold 20 gr. (1.25 grams. ) 

Acetate of soda 1 oz. (30 grams.) 

Water 20 oz. (625 c. c. ) 

Keep slightly alkaline by frequently adding sodium bicarbonate. 
Of the stock solution take an ounce, dilute it with ten ounces of clear 
water ; it is then ready for use. 

Put the prints into this solution; keep them moving, thus insuring 
even toning. If the toning be too slow, a few drops of the stock solution 
should be added to the diluted toning solution. On the other hand, if the 
toning is too rapid, a small quantity of water should be added. Usually 
from 15 to 20 minutes are required to bring out an even and proper 
tone. After the toning process is completed, the prints are thoroughly 
washed for some time in running water. The prints are next introduced 
into a fixing bath which consists of 

Hyposulphite of soda 2 oz. (60 grams.) 

Water 20 oz. (600 c. c.) 

In this solution they should be allowed to remain for at least 15 or 
20 minutes, keeping them in motion. All these processes should be 
conducted in a dimly lighted room. 

Mounting. After the prints have been thoroughly fixed, they are 
again washed for several hours in running water. They are next placed 
separately on a plate of glass (face downward) before drying, and all the 
wrinkles are rolled out by blotting paper. The back of each print is now 
painted with photographic paste and mounted on stiff card-board. Blot- 
ting paper is placed on the face of each print, and a roller used before the 
print has dried, to remove any wrinkles. 

Positives. Another method of printing consists in placing the X-ray 
negative into a regular printing frame, and a sensitive plate behind it. 
Everything being in total darkness, light a match and expose the plate 
for 5 or 8 counts. Develop the plate in the usual manner, the result be- 
ing a u positive. " These positives are the exact size of the negative 
(contact print), while transparencies and lantern slides are reduced in 
size. If prints are made from these positives, the bones will appear 
white, the fleshy parts dark, etc. , similar to the appearance of the original 
negative. 



224 ELECTRO-THERAPEUTICS. 

Transparencies and Lantern Slides or Diapositivcs. The reduced trans- 
parencies appear with fuller detail and are easily handled and convenient 
for exhibiting purposes. The reduced transparency can be obtained by 
putting the original negative in a camera or window, the negative being 
transilluininated and focused over a 4 x 5 inch (10 x 12.5 cm.) sensitive 
contrast plate and developed. If a smaller sized plate be used, 3J x 4 
inches (8.2 x 10 cm.), we obtain a lantern slide for projection. In 
making prints from these negatives, the bones, for example, will appear 
white, a circumstance that will often prove useful. 

Batelli and Garbasso were the first to suggest the wisdom of obtain- 
ing reduced photographs from images observed on the fluoroscopic 
screen, the advantage being that small-sized plates may be readily em- 
ployed. But certain disadvantages of the method at once present them- 
selves. The image on the screen must be steady, and there is required 
an ortho-chromatic plate, with a long exposure, as the image formed is 
yellow in color. The process is not well developed as yet, but when it 
is, an additional precaution will be the protection of the camera from 
the rays. 

IV. Interpretation of X-ray Negatives. 

This is more difficult than making the negative, because of the 
superimposition of shadows of varying densities. The trained eye of 
the X-ray specialist alone, can indisputably interpret the negative with 
any degree of correctness. 

The negative should be a satisfactory one of the special structures 
under examination. If it is found to be unsatisfactory, a duplicate should 
be made ; if this is not easily procurable, the negative can be improved 
by the process that I have mentioned in the chapter devoted to pho- 
tography. In those cases where difficulty is encountered in arriving at 
a positive diagnosis it is imperative that a duplicate be made in order 
to confirm the earlier diagnosis. 

A blurred negative cannot be remedied and is in every way inferior 
to an under- or an over-exposed plate. 

The skiagrapher should keep full data of the techuic when making 
the negative. He should always endeavor to interpret it correctly and 
to compare it with a negative of the corresponding part in the same 
individual ; he should study each part and its anatomy, and make him- 
self thoroughly informed upon every subject that comes to him for 
diagnosis and opinion. 

How to View the Negative. It is of prime importance to know the 
exact relations of the tube and the position of the part to the plate. 

The X-rays emanate from a small point on the anode, diverge, and 
then traverse the object, casting enlarged shadows on the fluoroscope or 



THE PRINCIPLES OF TECHNIC. 225 

plate. The collections of silhouettes are therefore superimposed i. e., 
there is a composite of the shadows of the object near the tube and those 
near the plate. When a negative is dry and ready to be examined, the 
eye of the skiagrapher or observer should take the place of the anode of 
the Crookes tube, the film or gelatine side facing the interpreter's eye, 
equal to the distance of the tube from the plate. 

Suppose that the right palm is in contact with the sensitive side of 
the plate, when examining the negative, it follows that the negative will 
be seen when the gelatine side is toward the observer's eye ; but if the 
observer's eye corresponds to the Crookes tube, then the dorsum of the 
hand will be brought into view. On the contrary, with the glass side 
toward his eye, the observer views the dorsum of the left hand or palmar 
view of the right hand, which is equal to the fluoroscopic view or a 
print. For instance, a patient is in the dorsal position, the plate placed 
against the back and the tube over the sternum, with the gelatine side 
(film) toward the observer's eye and the eye corresponding to the 
Crookes tube ; then this negative will show as though the observer were 
looking through the anterior wall of the thorax ; the left side of the 
patient will be his right side and vice versa. 

If you examine this negative with the glass side towards your eye 
(which is equal to placing the. fluoroscope to the back, or looking at a 
print) the right side of the patient will be your right side, etc. 

If a ventral or anterior view is taken, place the plate in front of the 
chest and the tube posterior ; when this negative is examined (film side 
towards the eye), the patient is viewed through the back, his right side 
will be your right side, etc. , but if you look at the glass side of the neg- 
ative, then this will be equal to the fluoroscopic view or a print, L e., the 
patient's right side will be your left side, etc. 

I prefer to make the examination or interpretation directly from the 
negative and not from the prints, because prints reverse the views. If 
we look at prints of the anterior view of the thorax, our eyes do not 
correspond to the anode of the Crookes tube, but we are looking at the 
front of the chest and rays are coming through the back of the patient ; 
we call this the ventral view, etc., i. e., the view or part that is next to 
the gelatine side of the plate, the fluoroscope, or print, or its equivalent 
to the negative glass side toward our eyes. The negatives should be 
placed or held with the gelatine side toward the examiner's eyes, because 
in this position, we look through the object and see its shadows more 
correctly and truer in their relation to each other. There will likewise 
be no reflection of light from the film, as there will be from the glass 
side. The negative can be held by the examiner who manipulates it, by 
viewing it from different angles, or an assistant holds the plate and the 
operator examines it from different distances and angles. 

15 



226 



ELECTKO-THERAPEUTICS. 



A better plan is to place the negative in a window, lower the cur- 
tain, and allow the light to come through the negative. I often prefer 
to place the negative in the window of the dark room and examine it 
either alone or by a similar negative of the corresponding part of the 
same person ; if this be not possible, I employ the negative of some 
other person and then compare them side by side. Another easy method 
is to place the negative in a photographer's retouching desk, which is so 
very convenient for small negatives. 

I have devised a viewing box (Fig. 109) which I employ at the 
Philadelphia Hospital. This box accommodates any sized negative and is 
capable of rotation, and thus without any displacement the negative can 
be viewed at any angle and also in the vertical or horizontal position. 




FIG. 109. Author's negative-viewing box. 



This box contains three series of eight c. p. lights behind the ground 
glass. When a dim or weak light is desired for less dense negatives, one 
series of lamps is lighted ; if strong light is desired, the Xo. 2 switch is 
turned on and greater illumination is produced. This box contains per- 
forations and is lined with asbestos. The preferable light for the exam- 
ination of negatives is white (day) light or the electric light. The 
intensity of the light can be regulated, by the interposition of either 
ground glass or a rheostat, as necessity requires. 

A. FOREIGN BODIES. 

In interpreting a negative for a foreign body, exclude all possible 
errors, such as white spots produced by air bubbles during development, 



THE PKIXCIPLES OF TECHXIC. 227 

the presence of iodoform, lead water and laudanum, etc., that may be on 
the bandage or dressing. Metallic foreign bodies will eclipse all other 
shadows. When semi-opaque bodies cast their shadows on those of the 
bones the contrast may be only very slight, especially so, when the plates 
are undeveloped. Small bodies in the deeper portions of the body (as 
for instance in the abdomen and in bony cavities, as the eye) may defy 
detection if the time of exposure is prolonged and secondary rays produce 
fogging on the plate. This occurs especially when the foreign body is 
non-metallic, i. e., a fragment of stone, etc. 

B. FRACTURES AND DISLOCATIONS. 

Green-stick fractures and impacted fractures are often difficult to 
recognize. If the rays do not penetrate the separated fragments, the 
shadows will be superimposed, and the characteristic dark line on the 
negative will not be visible ; in impacted fractures instead of this dark 
line there will appear an increased white shadow. Epiphyseal lines 
should not be lost sight of. The elbow-joint in children should be 
compared with the corresponding normal side. 

Fractures of the Hip- Joint. In these fractures note the changes oc- 
curring, even if the dark line on the negative is not visible ; and also look 
for any change in the continuity of the periosteum, the shape and relation 
of the femoral neck to the trochanter, etc. Compare the normal hip-joint 
with the affected one, and take a skiagraph of both hips on one large 
plate, being careful to observe the position of the feet. 

Dislocations. This condition can be discerned easily. The relations 
of the heads of the bones may often be disturbed or changed either by a 
peculiar position that the part may assume, or by a faulty relationship 
in the position of the tube to the plate ; this frequently occurs in the 
shoulder-joint, in the acromio-clavicular articulation, etc. Intra- articular 
cartilages are transparent to the rays and may thus be mistaken for a 
dislocation. 

The ventral and dorsal positions of the shoulder -joint present differ- 
ent appearances on the negative. 

C. DISEASES AND TUMORS OF THE BONES. 

It is important to determine if the growth is osseous or of muscular 
origin. Whenever possible the shadow should be cast in the light field, 
and note should be made whether the shadow is attached to the perios- 
teum or to the central portion of the bone. Do not diagnose the bony 
normal ridges, grooves, or projections as irregularities of the compact 
portion of the bone. The early stages of any special bone disease are dif- 
ferentiated with difficulty from other osseous diseases by the appearance 



228 ELECTRO-THERAPEUTICS. 

offered on the negative, as nearly all bone affections produce an increase 
in shadow density. Such a negative may assist the physician as to the 
origin and the exact location of the disease, and as the disease advances 
the characteristic appearance of that particular disease of the bone on the 
negative will be noticed. 

Callus. The appearance of callus can be diagnosed from periostitis, 
or other diseases, by the deformity produced and because the shadows 
are fusiform and encircle the ends of the fragments. 

Diseases of Joints. Endeavor to obtain an intra-articular space as 
wide as possible. Bandages and dressings should always be removed. 
Ordinary arthritis is differentiated with difficulty from the other arth- 
ritic affections in their early stages. Pus and fluid, whether serous or 
purulent, cannot be easily differentiated, although serum casts a denser 
shadow than pus. 

Iiitra-articular inflammation with exudation, can be differentiated 
from a periarticular inflammation, because the intra-articular space of the 
former is increased on account of tae tension exerted. 

False and true ankylosis should be carefully differentiated. Bony 
ankylosis may be excluded by the absence of dense shadows, or by the 
obliterated intra-articular space, which is absent in false ankylosis. In 
advanced cases deposits of tophi are demonstrable, and one can observe 
with certainty whether the disease is intra-articular or periarticular in 
origin. 

In hip-joint disease or in any other disease of the bone or joint, the 
true conditions or size of the bone may be altered, diminished, or increased, 
either by being nearer to the plate (as the result of atrophy of the muscle 
from, disease), by disuse, or by other causes that may exaggerate the 
normal size of the bone on the negative. 

D. DISEASES OF THE SOFT STRUCTURES. 

It is very difficult in these conditions to skiagraph or to obtain a 
clear shadow on the negative, and even when once obtained it cannot be 
differentiated from similar conditions, as lipoma, sarcoma, cyst, etc. A 
soft negative, full of details, is most desirable, and may be easily obtained 
by slightly under-developed and properly exposed plates. 

Brain tumors are very difficult to diagnose. Thickness of hair, 
especially in female subjects, should not be mistaken for a neoplasm. 

E. DISEASES OF THE THORACIC ORGANS. 

Negatives of the thorax should be examined in a viewing box. The 
skiagrapher should be familiar with the fluoroscopic appearance of the 
normal and of the pathological lung. The physical examination should 
always precede the skiagraphic examination. When the plate is placed 



THE PBIKCIPLES OF TECHNIC. 229 

over the anterior wall of the thorax, the negative will reveal the cage-like 
appearance of the thorax ; the anterior portions of the ribs will appear 
sharp and distinct, and will form an angle with the posterior portion. 

If the negative has been exposed in contact with the back of the pa- 
tient, then the posterior portion of the ribs will be more distinct than the 
anterior portion, the latter being further from the plate. If the time 
of exposure is prolonged, these anterior portions of the ribs will be 
indistinct and widely separated. The shadow of the diaphragm will be 
more distinct on the affected side, being less mobile during the exposure. 

In comparing the transparencies of the apices of both lungs in right- 
handed persons, the right side may appear lighter on the negative. 

In viewing the anterior wall of the chest examine the intercostal 
spaces ; do not mistake the shadows of the anterior portion of the first 
rib (often cast between the 2d and 3d intercostal spaces), or the sternal 
end of the clavicle (which may show an increased shadow), for consoli- 
dation. The shadows of the sternum require most careful observation and 
the shadows of the scapula will often be cast outside of the thorax. The 
female mammary glands throw pronounced shadows. 

In the incipient stage of tuberculosis, the apices of the lungs must 
be studied with great care, as a slight degree of congestion or infiltration 
will throw a shadow on the affected side. If one apex is diseased, the 
diagnosis will be arrived at with less difficulty, because an opportunity is 
afforded for comparison with the normal apex. Do not compare the 
transparency of one apex with other portions of the lung, but apex with 
apex, etc. ; for as the thickness of the thoracic wall differs in different 
parts, so does the transparency vary in the same person. 

Bronchial or lymphatic glands when calcified (and which are tuber- 
culous) , can often be observed without difficulty ; small areas of consoli- 
dations will appear as irregular scattered light patches. Longitudinal 
streaks on each side of the heart are supposed to be due to the foldings 
of the pleurae, when the latter are viewed edge-wise. Upon the nega- 
tive the posterior view shows the ribs very clearly and distinctly, and 
likewise the vertebrae. The anterior portions of the ribs, however, 
are blurred, because the posterior ribs are nearer to the plate and are 
immobilized. 

Abscesses and empyema do not cast shadows so dense as does consoli- 
dation ; neither do the former obscure the shadows of the ribs. Pleural 
thickening is differentiated from effusion in that the latter casts a uniform 
and more dense shadow ; the level of the shadow will change with the 
position of the patient and is best viewed in the erect or sitting posture. 
In thickening of the pleura an irregular outline is discernible. 

In consolidation the shadows are larger, more irregular, and denser 
than those cast by the ribs, and especially noticeable in advanced cases, 



230 ELECTRO-THEKAPEUTICS. 

of tuberculosis. The apex alone may be affected, but in other instances 
the entire lung is attacked. It is thus that consolidation is differentiated 
from effusion. 

Cavitations are characterized by dark areas surrounded by a light 
field ; this is due to a lessened amount of tissue for penetration by the 
rays. If the cavity is partly filled with fluid while the patient is in the 
recunibeut posture, the fluid gravitates, and the dark area is obliterated; 
but in the erect or sitting posture the level of the fluid will be visible 
when it is of considerable size. 

Prior to a paroxysm of severe coughing, if a fluoroscopic or skia- 
graphic examination be made with the patient in a recumbent position, 
and another examination taken subsequent to the paroxysm, the cavity 
will be noticeable, because the fluid, pus, etc. , will be evacuated. 

Emphysema is manifested by excessive darkness on the negative, due 
to the presence of air in the lung, as is also observed in cases of pneumo- 
thorax, etc. 

The shadows of the ventricles, the auricles, and the aorta are easily 
recognized ; for a detailed account, the reader is referred t6 the chapter 
devoted to the Circulatory System. 

I have made stereoscopic skiagraphs of the thorax which are very 
useful in differential studies in pulmonary and cardiac affections. 

F. ALIMENTARY SYSTEM. 

Stricture of the oesophagus, whether due to a growth within or exter- 
nal to and compressing the ossophagus, is difficult and often impossible to 
differentiate by the skiagraphic appearance ; but if the growth is within 
the oesophagus and the latter cannot be dilated, it becomes necessary to in- 
troduce an cesophageal bougie ; on the other hand, if the growth is external, 
the sound can be introduced by displacing the growth to one side. 

The Stomach. The reader is referred to Chapter V., Alimentary 
System. 

G. GENITO-URINAEY SYSTEM. 

Only in emaciated individuals are the shadows of the kidneys easy 
of demonstration. In the normal individual, shadows of the kidneys as 
seen on the negative are very unsatisfactory. 

Renal calculi should not be mistaken for biliary calculi, intestinal 
concretions, enteroliths, tuberculous foci, or abscesses. Scars and accu- 
mulations of sand in the pelvis of a kidney may in some cases cause an 
erroneous diagnosis to be made. I once mistook an undissolved capsule 
of bismuth for a calculus, but a second negative showed the change in the 
position that the capsule assumed, and the operation was postponed. 



THE PRINCIPLES OF TECHNIC. 231 

Dr. Henry Hultz 1 reported a case iii which fracture of the transverse 
process of a vertebra would have been mistaken for a calculus had he not 
made a stereo-skiagraph of the condition. Whether a calculus is in the 
lower part of the ureter or in the bladder, is often a difficult matter to 
decide. 

There are three methods for ascertaining the exact location of a 
calculus. 1. By inflating the bladder, when the shadow cast will be 
darker on the negative. 2. By injecting water, when the shadow will 
be seen to be lighter than the surrounding structure. 3. By introduc- 
ing a catheter, when the presence of a (small) stone in the ureter will be 
noticed by its position, and relation to the end of the catheter. By the 
first and second methods the relation of the calculus to the bladder will be 
observed. 

Several small round white spots often mistaken for calculi may be 
noticed along the left line of the ureter. They are frequently situated in 
a curved line and are more frequent on the left side than on the right, or 
sometimes on both sides of the same patient. They commonly occur after 
the thirtieth year. Their true nature is a disputed matter. Some believe 
them due to the presence of sesamoid bones in one of the obturator 
tendons. 2 Eussell H. Boggs is of the same opinion ; others incline to the 
belief that they are calcified glands. 

Dr. Joseph F. Smith, 3 of Chicago, believes that in 25 per cent, of his 
cases negatives of the pelvis contained from one to six small round 
shadows, sometimes on one side, sometimes on both sides, in the vicin- 
ity of the ischium. He found, by dissections of cadavers, that these 
shadows are caused by small bony deposits that occur in the pelvic liga- 
ments, especially in those attached to the spinous process of the ischium. 
I concur with those who believe that these spots are phleboliths. Among 
the latter may be mentioned Chas. L. Leonard, Henry K. Pancoast, and 
Max Eeichman. 4 These shadows can be differentiated from those of 
ureteral calculi by passing a metallic bougie and by skiagraphing in situ. 
If these shadows are outside the shadow of the catheter, they are evidently 
not ureteral. The autopsy of one of my cases showed the presence of a 
phlebolith. 

Vesical Calculi. The shadows of the sacrum and coccyx may be 
superimposed by the shadow of a small calculus, hence the shadow of the 
latter may fail of differentiation. This is also true of the shadow of 
impacted fecal matter in the rectum. The bladder should be evacuated 
just prior to the X-ray examination, as water offers a barrier to the 

1 Transactions of the American Rontgen Ray Society, 1906, page 158. 

2 E. W. Caldwell, Medical News, April 22, 1905. 

3 Transactions of the American Rontgen Ray Society, 1906, p. 157. 

4 Fortschritte a. d. Gebiete der Rontgenstrahlen, Feb. 22, 1906. 



232 ELECTRO-THERAPEUTICS. 

passage of rays. I have frequently seen the outline shadows of the 
bladder, which are so valuable in determining whether the calculus is 
ureteral or vesical, or if the appearance is due to an interfering shadow. 

In stricture of the urethra, by the introduction of a bismuth solution 
we are enabled to ascertain the location of the stricture, its calibre, etc. 

A report of the X-ray negative should be written or oral and should 
be most carefully executed. The report should be made as intelligible 
as possible, by making some tracing, marking, etc. 

There are numerous shadows on the negative that defy all efforts at 
interpretation and are as little understood to-day as they were when 
skiagraphy was first presented to the notice of the medical profession. 

V. Stereo-Fluoroscopy and Skiagraphy. 
A. HISTORY AND PRINCIPLES. 

The application of the principles of stereoscopy to skiagraphy was 
first employed in this country by Professor Elihu Thomson l and subse- 
quently used abroad. 

Ch. Bouchard 2 claims priority of the discovery for Imbert and Bertin, 
of Montpellier, France, but this is erroneous, as the latter first made 
known their studies in Comptes-Rendus, March 30, 1896. 

Dr. Mackenzie Davidson was perhaps the first investigator to pro- 
duce and interpret X-ray photographs by this method, publishing an 
article in the British Medical Journal in 1898. 

Professor G. P. Girdwood, of McGill University, Montreal, Canada, 
made extensive use of this method in studying foreign objects. The 
leading scientific journals of Germany have published many articles on 
this subject, describing the methods, the apparatus, and detailing advan- 
tages gained by its employment. 

In October, 1901, Dr. Louis Weigel, of Rochester, exhibited a stereo- 
scopic outfit before the members of the New York Medical Society, and 
Dr. A. B. Johnson, of New York City, published an article on this sub- 
ject in the New York Medical Record, September, 1900. 

In order to produce a stereoscopic picture, it is necessary to arrange 
a pair of tubes so that when worked simultaneously they will present on 
the fluorescent screen a double set of outlines fused into one. To bring 
out this effect we must alternate the use of the tubes, and so choose the 
intervals that the continuity of vision may accomplish the fusion of the 
two images. (Figs. 110, 111.) 

The anodes are placed about 6 cm. distant from each other. They 
are alternately excited by a single coil, but preferably by individual 

Electrical Engineering, March 11, 1896. 
2 Trait^ Radiologie Me'dicale, p. 561. 



THE PEIXCIPLES OF TECHXIC. 



233 



coils. The terminals of the secondary coil are connected to the tubes 
alternately, by means of a commutator or switch worked automatically. 
It is also necessary to have a revolving opaque disk containing two 
apertures on directly opposite sides, and set apart from each other at a 
distance corresponding to the space between the examiner's eyes. 

If the sector disk and the automatic switch rotate synchronously, 
and are so adjusted that the tube on the left side becomes luminous 
simultaneously with the passing of the aperture for the eye of that side, 




FIG. 110. Principles of Brewster's refracting 
stereoscope. 



FIG. 111. Principles of Wheatstone's reflecting 
stereoscope. 



there may be observed a sharp image on the fluorescent screen between 
the left tube and the perforated disk ; this is suddenly followed by an 
obscuration of the vision of the left eye. In this instance the tube is 
suddenly thrown into illumination and the image of the part is thrown 
upon the screen. Dr. Davidson 1 constructed such an apparatus. 

B. STEREO-FLUOROSCOPY. 

Briefly, this stereoscopic fluoroscope consists of a fluorescent screen 
illuminated by two tubes which spark alternately. A rotating disk with 
appropriately placed slots eclipses each eye alternately and works syn- 
chronously with the sparking of the tubes. Each eye sees the shadow 

1 Dr. Mackenzie Davidson described the mechanism of his invention, together 
with the application of its principles, before the Rontgen Ray Society of London, on 
December 6, 1900. 



234 ELECTEO-THEEAPEUTICS. 

cast from one tube. A stereoscopic image is thus seen, the movements 
of the shutter, etc., being sufficiently rapid to give a continuous 
illumination of the screen. 

E. W. Caldwell 1 uses a large Crookes tube of the double focus 
variety (two anodes) at a distance of three inches. The fluoroscope is 
provided with a shutter which permits only one eye at a time to view the 
fluorescent screen. In other respects the apparatus is very similar to 
Davidson' s device. 

C. TECHNIO OF STEREO-SKIAGRAPHY. 

In brief, the technic consists of obtaining two separate skiagraphs 
of the same part, or of employing two different sensitive plates without 
changing the position of the parts, but in alternating the position of the 
Crookes tube two and a half to two and three quarters inches (6 cm.), 
corresponding to the distance between the pupils. (Fig. 112.) Subse- 
quently these two negatives or skiagrams should be examined with a 
special instrument. It is important to observe that the part on which 
the stereoscope is to be used should first be fluoroscoped or skiagraphed 
in order to locate accurately the seat of the injury. 

For use in stereoscopic work, a plate- changing box (Fig. 113), with 
a top of thin wood or hard fibre and measuring from 14 to 17 inches (35 
to 45 cm.), is employed. The size of the plates is marked upon its top, 
in order to correspond with the dimensions on the drawer of the box. 
Over this box are placed cross- wires, which facilitate the accuracy of 
superposition. It is advisable to have a horizontal bar scaled in inches 
and centimetres. The skiagrapher should first centre the object and then 
move the tube to the right, corresponding to the vision of the right eye, 
one and one-quarter inches, or 3 cm., and procure a picture. Place 
another plate in the drawer of the box without moving the object, and 
adjust the tube to the left, corresponding to the view of the left eye, and 
again take a picture. The plates should be marked "right " and " left," 
to obviate confusion after photographing the part. 

Some operators use two Crookes tubes at a distance (the anodes) of 
seven or eight centimetres, not moving the tube at each exposure. The 
objection to this method is, that the two tubes will have different de- 
grees of vacuum. 

A. B. Johnson, of New York, and P. Czermak prefer to shift the 
box two and one-half inches instead of sliding the tube. 

Another method of taking stereoscopic pictures 2 is to have a plate- 
holder so constructed that, by a heavy sheet of metal, one-half the con- 
tained photographic plate is shielded from the action of the rays. After 

1 Electrical Review, November 16, 1901. 

2 A. B. Johnson, Annals of Surgery, April, 1902. 



236 



ELECTEO-THEEAPEUTICS. 



exposing one-half the plate, the other half is brought beneath the part, 
the latter having been previously shielded by a lead screen. The tube 
is moved a suitable distance, and a second exposure is made. The 




FIG. 113. Author's plate-changing box. 

Q 

two pictures thus lie side by side upon the same plate, and may be 
copied in a reduced size, and viewed as positives on glass or paper in a 
refracting stereoscope. This method is suited for the extremities, but 
not for the chest, abdomen, etc. 

Marie and Eibaut 1 have derived the following formulae and table, 
which they assert will give the most relief and perspective view without 
fatiguing the operator's eyes. They arrived at these deduced results by 
a series of experiments founded upon mathematical proofs: 

A Maximum = The maximum displacement of focus tube. 

D = The distance of the tube from the surface of the object. 
P = The thickness of the object. 

D (D + P) 
A Max. = - 

50 P 

1 Archives d'electricite medicale experimental es et cliniques, viii., July 15, 1905, 
and Traite Radiologie Medicale by Bouchard, pp. 565 and 566. 



THE PRINCIPLES OF TECHNIC. 



237 



When the actual size (dimension) is desired, then /\ is equal to 6.6 
cm. viz., the distance between two pupils. 



6 . 6 cm. = 



L) (D _ P) 
50 P 



Marie and RibauVs Table, showing the varying relationships between 
the thickness of the part examined and the displacement of the Crookes 
tube, and also the change in the distance of the tube from the surface 
of the object. For example, if the part, such as the wrist, is 6 cm. in 
thickness and the distance of the tube is 40 cm. , then the displacement 
of the tube will be equal to 6. 1 cm. 



P = THICKNESS 

OF THE OBJECT. 



D = DISTANCE OF THE TUBE FROM THE SURFACE OF THE OBJECT. 



Inch. 


Cm. 


8 
Inch. 


20 
Cm. 


12 
Inch. 


30 
Cm. 


15f 
Inch. 


40 
Cm. 


191- 
Inch. 


50 
Cm. 


23* 

Inch. 


60 
Cm. 






= MAXIMUM DISPLACEMENT OF CROOKES TUBE. 


I 


2 


If 


4.4 


31 


9.6 


6 T 6 -T 


16.2 










1A 

2* 


4 
6 


it 
If 


2.4 
1.7 


2| 

If 


5.4 
3.6 


Si 

2T 6 * 


8.8 
6.1 


5 T 5 * 

s 


13.5 
9.3 






S| 


8 


1 


1.2 


if 


2.8 


m 


4.1 


2 


7.3 






4 


10 






H 


2.4 


lr 9 * 


4.0 


2A 


6.0 






6 


15 






! 


1.8 


U 


2.9 


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4.3 


21 


6.0 


7} 


'20 






H 


1.5 





2.4 


1A 


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it 


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III 


25 
30 






A 


1.3 
1.2 


U 
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2.1 
1.9 


1A 

1A 


3.0 

2 .7 


If 
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3.6 



I have devised a special table and an adjustable plate-holder, which 
I believe possess many advantages. 

The table is so constructed that the tube can be made to slide 
on a rod with great ease, whether on the top, bottom, or side, without 
discomfort to the patient. 

Usually in skiagraphing for either simple or stereoscopic purposes 
the part is placed over the table or plate -changing box, and the weight 
of the patient rests upon the plate, thus changing the original position of 
the foreign body. With the above device, the part may be placed in a 
natural position, without the plate-changing frame touching it at any 
point. 

To produce two negatives of " equal density " the degree of penetra- 
tion of the rays should be as nearly uniform as possible, and great care 
should be exercised in development. 



238 



ELECTRO-THERAPEUTICS. 



No two tubes have exactly the same degree of vacuum, the same 
tube changing its vacuum during the exposure. The operator should 



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STEREOSCOPIC 
EFFECTS. 


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fi Q) 
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ID 
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Pseudo- 
stereoscopic or 
conversion. 
See Fig. 112, B 


rue stereoscop 
effect. 


Pseudo- stereo 
scopic effect. 




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qp 


ID 




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POSITIONS OF THE 
NEGATIVES. 


1m side toward 
the reflecting 
mirrors; similar 
to fluoroscopic 
view or skiagram. 


i- 1 ! 0^2 

g O 3 y 60 


lass side toward 
the mirrors (skia- 
grams), eyes cor- 
responding to the 
Crookes tube. 


lass side toward 
the mirrors (skia- 
grams) . 




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ijii 


























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judge the time of exposure of the second plate by experience. A self- 
regulating tube is preferable. I usually give a little longer time for the 
second exposure than for the first, as the tube runs down a little and the 
penetration lessens. Short exposures are most desirable. 



THE PRINCIPLES OF TECHNIC. 239 

Lately I have been developing for the same duration of time two ex- 
posed plates in one tray, but I have discarded this method, because the 
handling of large plates is difficult and the plates differ in density, but 
now I develop them separately, and by carefully mixing the developer 
before and during the progress of development, I alter it as the plate 
requires, to secure equal densities. Soft negatives are preferable. 

D. METHODS OF VIEWING STEREO-SKIAGRAMS. 

Wheatstone's Reflecting Method. This instrument, devised in 1838, 
consists of two vertical mirrors accurately set at a right angle (the ver- 
tex of the angle facing the middle line of the observer's forehead), this 
arrangement of mirrors slides forward and backward, and is placed over 
a long board, upon which is a vertical frame parallel with the reflecting 
plane, forming an angle of 45. These frames and mirrors are so con- 
structed that the observer can easily superimpose the two pictures. 
(Fig. 114.) 

The pictures must be so placed in the frame as to hold the same 
position as that occupied by the Crookes tube during exposure. For 
instance, the picture marked l i right ' ' should be placed in the frame to 
the right of the observer in order to get an anterior view of the part. If 
placed in the left-hand frame, a posterior view will be obtained. When 
prints are examined with reflected light, by turning the prints end for 
end, without changing the u R ' or li L " positions, posterior and anterior 
views may be obtained ; this is known as pseudo-stereoscopy. 

The advantages of Wheatstone's reflecting method are that : Any 
sized negative, even before a print is made, can be viewed. When nega- 
tives are used without prints, the picture is seen more in detail ; nega- 
tives can be examined while wet. I bore two holes in a block of wood 
which is placed between the reflecting mirrors, where the same reflecting 
light used for negatives can be set for the illumination of prints. 

Brewster^s refracting or lenticular stereoscope is founded on the prin- 
ciple that two pictures can be produced, by causing a displacement of the 
tube, two and one half inches (6.5 cm.), with the pictures side by side, 
and viewed with two prisms (18) for each eye. (Fig. 110.) 

These pictures will be superimposed according to the laws of refrac- 
tion. One disadvantage of the Brewster refracting stereoscope is the 
great degree of the convergence of the axis of vision required, and the 
necessity of reducing the size of the pictures for use in this refractor. 
This has been overcome by Walter, of Germany, who places the original 
size negative in the frame and views it with different prisms. (Fig. 115.) 

There is yet another method of viewing these stereoscopic transpar- 
encies or prints. The reduced pictures mounted in frames are placed on 
an endless chain, and are viewed by the operator who looks through the 



240 



ELECTRO-THERAPEUTICS. 



prisms. The advantages of this method are : That the number of pic- 
tures is practically unlimited, unnecessary light is excluded, and that 
prints as well as transparencies may be employed. 

Lately I have made some plastographic views from these stereo- 
scopic negatives. The plastographic method consists in superimposing 
one print in green over another in crimson, which offers a haziness to the 
naked eye, but when viewed through eye-glasses (one of a green color 
and the other of crimson), a very beautiful picture with marked relief 




Fie. 115. Prism stereoscope of Walter. 

details is afforded. I believe this process will be useful for stereo- 
scopically illustrating medical journals and scientific books. There is 
another method of combining stereoscopic pictures without an instru- 
ment, which can easily be acquired by crossing the visual axes. Place 
the skiagraph in front, hold up the index finger in the middle line 
between the eyes and the skiagrams, and while looking at the top of 
the finger, a third picture will appear in the centre, offering a most 
beautiful stereoscopic effect. 

E. ADVANTAGES OF STEEEO-SKIAGRAPHY. 

An ordinary skiagraph is composed of superimposed shadows of 
different densities, which appear flat on the negative or print, and in ad- 
dition contains many shadows appearing indistinct and weak, but in 
the stereoscopic pictures the superimposition will be more distinct 
and visible. Two plates exposed at different angles are used, and any 
deficiency in one is easily compensated for in the other. Another 




FIG. 114. Wheatstone's reflecting stereoscope, as modified by Weigel. 





FIG. 116. Stereo-skiagram of Colles's fracture, palmar view taken through the splint, and should be viewed 

with prism stereoscope. 



THE PRINCIPLES OF TECHNIC. 241 

advantage is that the anterior and the posterior views are discernible. 
In passing, we will very briefly note a few of the many applications 
of stereo-skiagraphy. 

Anatomy. For demonstrating the structure of the bones. In the 
long and short bones the trabeculse are seen, and in the long bones we 
may observe the lamellae in the shafts and in the cancellous tissue. 

The spiral arrangement of the lamellse is distinctly shown, especially 
in the humerus and femur, also its change in direction near the articular 
surfaces. 

In examining the skull, the grooves for the meuiugeal arteries are 
seen, the concave appearance of the cranial processes, the frontal sinuses, 
the antrum of Highmore, the turbinated bones, etc. 

In studying the mechanism of the joints, these pictures give a per- 
spective of the relations of the articular surfaces of the bones, their actual 
depths, and the relation of the processes, to the observer. 

Arteries, veins, bronchi, and excretory ducts, when injected with 
opaque materials, such as lead or mercury, show their exact relations 
(their depths) to the bones, the muscles, etc. 

Surgery. Of the numerous methods of locating foreign bodies stereo- 
skiagraphy is the most satisfactory, because it offers a definite view of 
the foreign body, and thus enables the surgeon to operate with cer- 
tainty. The negatives should be soft and full of details, in order to show 
shadows of different tissues, especially cystic and soft tumor tissue. 

AVhen two negatives of this kind are superimposed, the intensity of 
the shadow is doubled. I am and have been using this method in 
the Philadelphia Hospital in a series of experiments for detecting and 
locating brain tumors, etc. 

The foregoing statement is also true in regard to fractures. (Fig. 
116.) By this method we may procure definite views of the injuries, the 
exact position of the fragments, the amount of overlapping, the separa- 
tion, the degree of apposition in deformities, etc. The ordinary skiagraph 
does not show the variety and character of dislocations. The stereo-skia- 
graph overcomes this difficulty, and enables one to differentiate between 
an anterior and a posterior dislocation. We may view the thorax either 
from an anterior or posterior aspect. The heart and the aorta with their 
various relations are interesting and fascinating from a practical and 
scientific standpoint. In the study of normal and morbid conditions, 
I invariably resort to the employment of stereo-skiagraphy at the 
Philadelphia Hospital. 

Chromo-Stereo-Rbntgenograms. 

Before considering the great advance in the realm of Rontgenology, 
let us for a moment revert to the well-known principles involved in a 
study of ordinary stereoscopy. 

16 



242 ELECTRO-THERAPEUTICS. 

The stereoscope is an instrument so constructed that two flat pictures, 
taken under certain conditions, shall appear to form a single solid or 
projecting body. 

To produce this illusion, different images as observed by the two 
eyes must be depicted on the respective retinae, and yet appear to have 
emanated from one and the same object. Two pictures are taken from 
the really projecting or solid body, the one as observed by the right eye 
only, the other as seen by the left. These pictures are then placed in 
the stereoscopic box, which is furnished by two eye-pieces containing 
lenses so constructed that rays proceeding from the respective pictures 
to the corresponding eye-pieces shall be refracted at such an angle as 
each set of rays would have formed had they proceeded from a single 
picture in the centre of the box to the respective eyes without the inter- 
vention of the lenses. 

Founded upon this principle, M. Louis Ducos du Heron, a noted 
French photo-scientist 1 , demonstrated from his article entitled, "Produc- 
tion de phototypes pour 1'auaglyphie polychrome (stereochromie)," that 
for the purpose of viewing chromo-stereograms, "two colors, red for the 
image corresponding to the perspective of the right, and green corre- 
sponding to the perspective of the left eye, are found best." 

Recognizing the value attached to this study, I have made practical 
applications of the principles of the anaglyph to stereo-skiagraphy. 
These stereo-skiagrams are made in the usual way, i.e., right and left by 
displacing the Crookes tube 6 cm. (2 in.), and they may be viewed stereo- 
scopically either by the Wheatstone or Brewster method (page 239). 

The main object of ordinary stereoscopy is the superimposition of 
the two views by prisms or mirrors, but in my anaglyph process the 
right hand picture is painted or printed in red, and the left hand picture 
in the complementary color, green; these colored images not being placed 
side by side, as in the ordinary stereoscopic view, but superimposed one 
upon the other, so that they do not register exactly, but are made to 
suffer a slight overlapping (\ inch or 3 mm.) due to the object being skia- 
graphed at two different angles, by the displacement of the Crookes tube, 
i.e., the visual angle (6 cm. ). The Rontgenologist endeavors to superim- 
pose the images exactly, guided by cross- wires, but this exact registration 
of the parts is impossible of accomplishment, for the reasons stated above. 

Taking the stereo-skiagram in his left hand at a distance of from 10 
to 15 inches (25-35 cm.) the observer holds with his right hand a pair 
of spectacles or a card of pasteboard containing two apertures corre- 
sponding to the two eyes, the right aperture covered with red glass or 
celluloid, and the left with green glass or celluloid, and he may now view 
the stereoscopic relief effect produced. The right red glass will obliterate 

1 Bulletin de la Societe Franoaise de Photographic, 2e Serie, tome xii, No. 20. 



THE PEINCIPLES OF TECHXIC. 243 

the right red color of the stereogram, and he will observe only the green of 
that part of the picture, whilst the green will mask the green, but he will be 
able to see the red. The effect of blending these complementary colors is 
to offer a darkish photographic image that appears single to the observer. 

If we invert the picture (holding the image u upside down") and 
view it with the spectacles in the normal position, the anterior view (for 
instance, of the hand) appears as though the observer were looking at 
the posterior aspect; again the same result is produced if we reverse the 
spectacles, i. e. , applying the red glass to the left eye, the green to the 
right without inverting the picture. In other words, these changes will 
result in intaglio or cameo effects. 

The advantages gained by the anaglyph color process, in viewing 
Eontgenograms, may be summed up as follows: 

The superirupositiou of the stereograms causes little fatigue to the eyes. 

Those suffering with certain muscular troubles connected with vision, 
and to whom the ordinary prism method causes a blurred or imperfect im- 
age, will find this method of inestimable value in Edntgenological studies. 

One chromo-stereo-Eontgenogram occupies less space as an illustra- 
tion for a medical book or journal. 

The stereoscopic effects may be viewed by an assemblage wearing 
colored spectacles, when the lantern slides of the two colored projections 
are thrown on the screen. 

Plastic Rontgenography. 

This ingenious study originated with Dr. Bela Alexander, a Hun- 
garian physician, who exhibited before the Medical Society of Budapest * 
a series of photographs that offered a plastic reproduction of various 
bones, i.e., pictures in which the bones appeared to stand out in bold 
relief instead of the usual flat silhouettes. 

Besides the latter, there are discernible fine shadows, which very 
distinctly represent the structure of many of the softer parts. The 
technical completeness of Dr. Alexander's results is perfect. The finest 
details of structure are clearly shown, but what is more surprising is the 
manner in which the veins and arteries are so visibly depicted. It 
brings, out details which are present in the original negative, but, by 
reason of lack of the contrast, are not discernible to the unaided eye. 
Says Albers-Schonberg: 2 "I had come to the conclusion from my own 
experiments and from the observations of others interested in the subject 
that the so-called plastic Eontgenography was a very interesting photo- 
graphic plaything, but of no practical scientific interest. * * * Some time 

1 Budapest! Riv. Orvosegyesiilet, "Reliefszerii es Plastikus, Q-suguras kepek." 
Orvosi Hetilap, 1906. II. 

2 Archives of the Rontgen Ray, vol. xii, No. 90, Jan., 1908. - 



244 ELECTRO-THERAPEUTICS. 

ago Dr. Alexander showed me his results, and I had a better opportunity 
of thoroughly studying and testing them than is possible at a public 
exhibition. In consequence I have been compelled to alter my opinion 
completely. * * * I cannot doubt but this method has an assured future. 
Just consider what immense importance it may have in diagnosis of dis- 
eases of the lungs, in the recognition of renal calculus, and perhaps even 
of gall-stones ! The shadows of the abdominal organs, of the kidneys and 
those of the stones themselves, can, by this method, be emphasized and 
rendered much more easy of recognition. ' ' 

In a good skiagram of any part of the body the very richness of 
detail necessitates that some parts of the complicated structure must 
obscure other portions. For in such a skiagram, even to the critical- 
eyed, skilled interpreter, there must appear a mass of details quite invisi- 
ble in the ordinary skiagram a mere silhouette of the bony parts with 
an incomplete reproduction of their structure. 

The method employed in plastic Rontgenography is very simple and 
consists in taking a diapositive from the original negative, placing the 
negative and diapositive together, with the films outward, and then 
printing another diapositive from the combination. 

A plastic picture may likewise be obtained from the compound plate, 
but the sensitiveness of the film on the photographic plate is greater than 
that of the photographic paper; a reproduction, in glass, therefore, will 
be more exact and clearer. 

Dr. Alexander therefore usually prepares a third plate, a print 
on glass for a compound plate, and this for several reasons. A 
print from the third plate will be much sharper than a print made 
from the combination of the first and second plates ; again, in plate 
No. 3 we have a single plate from which additional prints can be 
made at a future time. Finally, when it is desired to compare the 
three plates, it is necessary to separate plates No. 1 and No. 2, which, in 
that case, cannot be permanently superimposed one upon the other. In 
order to reproduce this third plate on paper, we require a fourth plate, a 
negative from which copies may be produced in the usual manner. This 
fourth plate will of course be the reverse of plate No. 3, bearing to it the 
same relation as an ordinary negative to a positive. Prints from plate 
No. 4 will therefore be reproductions on paper of plate No. 3. These are 
found to be much clearer and more detailed than those made directly for 
the combinations of plates Nos. 1 and 2. There is, of course, no limit to 
the number of copies that can be made from the fourth plate. 

The original superimposed negative and diapositive are best studied, 
according to Alexander, on a black background. The soft parts should 
be of a bluish, almost blue tint, with the bones copper-colored, thus pre- 
senting a metallic lustre. Such a picture is far more instructive than the 




FIG. 116B. Congenital dislocation of the head of the left femur. 




FIG. 11GC. Plastic Rontgenogram of the above. 



THE PEINCIPLES OF TECHXIC. 



245 



original negative, for it portrays the details of the softer tissues, as well 
as the more conspicuous osseous images. 

Early in the study of relief Edntgenography the shadows of the bones 
were ordinarily much distorted, offering a wide divergence with the propor- 
tions and extent of the image as presented by the original radiogram. The 
result of Alexander's more recent procedures has entirely obviated this dis- 
tortion. This he proved by careful comparisons with the original negatives. 

When the part to be radiographed demands a plate of large size (as 
is required in studying thoracic and abdominal affections 14 by 17 




JL EC IE Iff W 

3 C D 

FIG. 116A. The author's method of plastic Rontgenography. 

inches (35 by 42 cm.) (Fig. 116A), I reduce this original large negative 
(I) to one of 4 by 5 inches (10 by 13 cm.) by means of the camera (A); 
from this I make a contact print on a slow plate in a dark room (B). I 
take this diapositive and place its glass side against the glass side of the 
already printed plate (C) and, instead of registering exactly, it is my 
practice to effect a slight lateral or vertical displacement, as the Eont- 
genogram requires. The plates are secured at their ends by binding- 
strips. They should be carefully viewed by daylight in order to see if 
the realistic effects are depicted. I place a developing paper or contrast 
plate in apposition with the gelatine side of the third plate (D), which 
is the reduced size of the original X-ray negative. All this is accom- 
plished in a dark room, with the aid of a printing frame and artificial 
light. I expose the paper or plate by holding the plate so that the 
light strikes upon it at its centre. My method is economical by obviat : 
ing the employment of large expensive plates, and the smallness of the 
plates facilitates their photographic manipulation. 



CHAPTER III 

THE CLimCAL APPLICATIONS OF THE RONTGEN BAYS. 

INTRODUCTION. 

I. The Uses of the X-rays in Anatomy and Physiology. 

MUCH has been written about the uses of the X-rays in investigating 
anatomical structures and in studying the functions of organs. Undoubt- 
edly the knowledge gained by dissection and vivisection through many 
years of laborious research has been greatly altered and modified through 
the application of the X-rays. 

A. BLOOD-VESSELS AND RESPIRATORY TRACT. 

I have studied the blood-vessels of infants and adults by injecting 
into them a substance opaque to the X-rays. The substance used is a 
concentrated emulsion of bismuth subnitrate, a strong solution of litharge 
(red oxide of lead), or metallic mercury. In order to demonstrate 
sharply the arterial tree, the injection must be done carefully and slowly. 
By some it is deemed advisable first to empty the arterial system of all 
its blood, and then to inject a solution of zinc chloride, so as to get rid of 
any existing clots. This solution should be removed by washing, or by 
forcing water into the arterial system, followed by an injection of metallic 
mercury, by a force pump connected to the external carotid artery. 

The kidney, heart, brain, spleen, liver, stomach, etc., may have 
their arterial systems demonstrated by first removing them from the 
cadaver, and then injecting into them some opaque substance, preferably 
lead oxide. In experiments performed two years ago, I showed the 
arterial and venous systems of a kidney by employing substances of 
different densities. Thus metallic mercury was used for the renal artery 
and its branches, and a weak solution of red oxide of lead for the renal 
vein and its tributaries. 

The brachial, radial, and popliteal arteries have been observed in 
the living subject, especially in the aged where sclerosis was present. 

I have traced the respiratory tract from the larynx to the small 
bronchioles, by introducing into the upper opening of the larynx a solu- 
tion of red oxide of lead and allowing it to expand the air-vesicles. 
The larynx, the trachea with its bifurcation, and the bronchi, with a few 
of its branches, can be beautifully demonstrated skiagraphically. Instead 
of the red oxide of lead, I have used small shot, which travel only to the 
smaller bronchioles, and not into the respiratory passages and air-cells. 
246 



THE CLINICAL APPLICATIONS. 



247 



B. BONES AND JOINTS. 

So far as the subject of anatomy is concerned, the X-rays have been 
most useful in studying the osseous system. AYhen the entire foetal 
skeletal system is mapped out in cartilage, the X-rays cast no shadows 
of these structures. As soon as ossification of the cartilaginous tissues 
begins and advances, every step involved in the process may be shown 
by X-ray skiagrams. The cartilage, being transparent to the rays, casts 
no shadow. 

The rays are of great value in estimating and detecting delayed 
union of the epiphyses. All X-ray specialists should be thoroughly 
familiar with the normal appearance of an epiphysis and the time of 
union. Mr. Poland, F.R.C.S., 1 London, states, that epiphyseal separa- 
tion is much more common in males, owing to their rougher forms of 
amusement, heavier work, etc., and also that the injury is frequently 
started in intra- uterine life or during awkward, difficult, and instru- 
mental labors. The larger number of injuries are produced during 
childhood, between the ages of five and ten and even up to the sixteenth 
year of life. 

The most frequent seats of epiphyseal lesions occur in the upper 
epiphysis of the humerus, lower epiphysis of the femur, lower epiphysis 
of the radius, and in the phalangeal and metacarpal and metatarsal 
epiphyses. The times of union of the various epiphyses to the corre- 
sponding diaphyses of long bones are as follows : 



UPPER EXTREMITY. 
Radius 
Radius 
Ulna 
Ulna 
Humerus 
Hunierus 
Humerus 
Metacarpal 
Phalanges (fingers) 
Clavicle 

LOWER EXTREMITY. 
Tibia 
Tibia 
Fibula 
Fibula 
Femur 
Femur 
Femur 



(upper end) 

(lower end) 

(end of olecranon) 

(lower end) 

(lower end) 

(upper end) 

(end of epicondyle) 



(upper end) 
(lower end) 
(upper end) 
(lower end) 
(lesser trochanter) 
(greater trochanter) 
(head) 



Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 



Between 
Between 
Between 
Between 
Between 
Between 
Between 



15 and 17. 

17 and 19. 

15 and 17. 

18 and 21. 

16 and 17. 

18 and 22. 

17 and 18. 

19 and 21. 

18 and 20. 
22 and 26. 



21 and 22. 

18 and 19. 
20 and 22. 

19 and 22. 

17 and 19. 

18 and 19. 
18 and 20. 



llt Traumatic Separation of the Epiphyses." A monograph published by 
Smith, Elder & Co., London, 1898. 



248 ELECTRO-THERAPEUTICS. 

LOWER EXTREMITY. Continued. 

Femur (lower end) Between 20 and 24. 

Metatarsal Between 19 and 21. 

Phalanges (toes) Between 17 and 21. 

{Ilium Between 7 and 10. 

Ischium Between 7 and 12. 

T> I,' T> i e J ir 

Pubis Between 6 and 15. 
(Uniting at 25) 

As an epiphysis consists of rapidly developing cartilage, it is readily 
penetrable by the rays, while a skiagram casts a light shadow of the 
epiphyseal band, which on the negative appears as a dark band. It is 
essential to diagnose correctly an epiphyseal injury, as it often results in 
severe deformity. Both sides must be taken for comparison. 

The joints and their mechanism have been carefully studied by Dr. 
Ernest A. Codman, 1 of Boston. He says : " This has been undertaken 
in two ways, first, by skiagraphing the normal joints in their extreme 
positions (extreme flexion, extension, adduction, etc.) ; secondly, by 
watching the movements with the fluoroscope. As the parts of the object 
near the plate show best, it is necessary to take each position from 
both sides. One thing which will arrest attention is the great distance 
that apparently intervenes between the bones. This is in part due to 
the fact that the articular cartilages, being easily traversed by the 
rays, do not cast a shadow. The wrist -joint has proved most interest- 
ing in this study, and the points brought out will be found in the fol- 
lowing description. For convenience we may consider the wrist -joint to 
be made up of four immobile and two mobile elements. (1) Immobile 
(i. e.j those made up of simple bones or of a group of bones, the com- 
ponents of which cannot change relative positions). These are : (a) 
metacarpal of thumb, (6) metacarpal of ring-finger, (c) metacarpal of 
index and middle finger, with trapezium, trapezoid, os magnum, and unci- 
form. This last group is so firmly attached to one another that they move 
as a whole, practically as one bone. No doubt, however, their liga- 
mentous attachments allow of more or less spring in strained positions of 
the hand brought about by external force. 

" 2. Mobile (the components of which change relative positions), 
(a) The intermediate row of carpal bones composed of scaphoid, semi- 
lunar, cuneiform, and pisiform. (6) Eadius and ulna. From skiagraphs 
it is found that the carpus and metacarpus are, in any of the extreme 
positions, in practically the same relation to the radius, no matter what 
the relation of the radius to the ulna, whether pronation or supination. 
This is due to the more or less flexible fibro- cartilage, which in any posi- 
tion completes the cups of the radial joint. The question of mechanism, 
then, is further simplified by leaving out the ulna, which really does not 

1 Archives of the ROntgen Ray, August, 1898. 



THE CLINICAL APPLICATIONS. 249 

enter into the construction of the joint except as a pivot. The pisiform 
also does not enter the mechanism, serving only as a sesamoid for the 
ulnar tendons. 

1 i Proceeding to eliminate other accessory elements, we can disregard 
the metacarpal of the thumb, ring and index fingers, each of which 
moves independently on the large fixed elements composed of the os mag- 
num, etc. The thumb forms a typical saddle joint with the trapezium, 
with the pommels of the saddle so low that motion is allowed in a small 
circle, either as rotation within the circumference or straight motions on 
any of the radii. The metacarpal of the ring finger is allowed a slight 
antero-posterior motion of a few degrees; that of the little finger the 
same, but of slightly greater extent, with possibly a degree of adduction. 
This leaves us with : (a) The large compound fixed element of the os 
magnum, etc. (&) The radius with fibro- cartilage, (c) The intermediate 
element of the scaphoid, semilunar, and cuneiform. These constitute the 
real wrist-joint. 

"By injecting a solution of paraffin in alcohol containing substances 
opaque to the rays, we may bring out the normal anatomical relations of 
certain of the internal organs. Thus, by injecting this charged solution 
into the urethra, bladder and ureters, vagina, Fallopian tubes, rectum, 
and the intestines, we may be able to produce exact skiagrams. To bring 
out the normal topography of the large intestines, inject with water, 
and allow it to escape from the small intestines through an incision previ- 
ously made ; this will remove the fecal matter, permitting the opaque 
solution to fill all crevices or depressions between the rugae. As has been 
previously stated, we may by the X-rays determine the movements of the 
heart in the living. The heaving of the diaphragm, together with the 
relationship this organ bears to the movements of the pulsating heart, 
may be illustrated by careful fluorescent screen examinations. ' ' 

M. Bouchard 1 reports that he observed a marked dilatation of the 
left auricle when the intra-thoracic blood pressure was raised during a 
deep and prolonged inspiration. The same condition exists when the 
inspirations of a whooping-cough paroxysm are most violent. In two 
cases examined with the fluorescent screen I was enabled to observe the 
same condition. During forced inspiration a clear space between the 
diaphragm and the heart may readily be demonstrated that does not exist 
during ordinary inspiration. 

C. PHYSIOLOGY OF PHONATION. 

The physiology of phonation as seen by careful screen examinations 
is very interesting. Max Scheier 2 was the first to investigate this subject. 

1 Lancet, September 10, 1898. 

2 Fortschritte a. d. Geb. d. Rontgenstr., B. i., 1897-1898. 



250 ELECTRO-THERAPEUTICS. 

In examining the parts involved during phonation, the X-rays should 
penetrate the head laterally, the screen showing clear shadows of the 
upper part of the pharynx and the naso-pharyngeal space. If the person 
under examination utters a vowel sound, the screen shows the velum to 
be raised, taking a position in the naso-pharyngeal space, the position vary- 
ing with the sound that is uttered. During the rendition of the vowel 
letter a, we may observe the velum to rise a little and become more and 
more elevated as the other vowels (in the order of e, o, u, and i) are suc- 
cessively uttered. In high tones the velum rises more than when low 
ones are uttered. 

If consonants (except resonants and semi-vowels) are pronounced, 
the velum is raised higher than when the sound i is uttered. If the sounds 
of the letters m, u, and ing are uttered, the velum rises only a very little 
and in many cases not at all. The movements and positions of the tongue, 
lips, and the inferior maxillary bone can also be easily interpreted on the 
screen. The movements of the larynx, velum, and other associated parts 
can easily be seen during deglutition, breathing, hawking, and sneezing. 

II. Diagnostic Value in Fractures, Dislocations, and Callus 
Formation. 

The employment of the X-rays in surgery has found a fertile field in 
the study of fractures, their frequency, character, and varieties. Only of 
late empirical knowledge has given way to scientific deductions, whilst 
improved and modified forms of treatment have followed in the wake of 
this recent achievement. 

The deformity associated with a fracture is often deceptive. It may 
be due to swelling of the neighboring tissues, occurring at the time of 
or subsequent to the accident. The diagnosis of a fracture is not pre- 
cluded by employing certain bony landmarks as guides in the diagnosis. 
Again, shortening does not occur in green-stick fractures, in those which 
are impacted, or in the iutra-articular or in the longitudinal fractures of 
small bones, such as the carpal or tarsal. 

Preternatural mobility is a sign of doubtful value. It often defies 
recognition in incomplete, intra-articular, and fissured fractures. In 
fractures near a joint it is often impossible to declare positively if the 
mobility proceed from the joint or from the supposed seat of fracture. 
Difficulty may be experienced in grasping the fragments, and rough 
manipulation exposes the patient to the danger of having a simple fracture 
converted into a compound one. 

Crepitus is likewise an unreliable guide in the diagnosis of fracture. 
Interposition between the fragments of muscle tissue, fascia, or granula- 
tions will mask the true condition. In incomplete, fissured, or impacted 
fractures of the neck of the femur and humerus, the nature and seat of the 



THE CLINICAL APPLICATIONS. 251 

injury may fail to elicit this sign ; again this difficulty may be encountered 
where muscular action maintains displacement and separation of the 
fragments, as in transverse fracture of the patella, olecranon, coracoid 
and acromiou processes of the scapula, etc. Lastly, teuosynovitis, move- 
ment of a rheumatic joint, and inflammation of a sheath or tendon may 
closely simulate crepitus. 

Movement of a broken bone or pressure at the seat of fracture elicits 
pain, but its presence is not positively diagnostic. Loss of function is 
another negative proof, as arthritis and painful joints will often cause 
this condition. 

A. THE ADVANTAGES OF THE BONTGEN BAY METHOD IN THE DIFFER- 
ENTIAL DIAGNOSIS OF COMPLICATED FRACTURES. 

The foregoing signs and symptoms are established facts based on 
clinical knowledge. They, however, do not manifest themselves in any 
given order, and are not typical, as they do not exist in all cases. They 
always require an observant eye, a trained ear, and an experienced touch. 
This method is supplemented by the X-rays, which for accuracy and 
reliability are far superior to it, and possess the following additional 
advantages : 

1. As a method of diagnosis it is painless. It entails no waiting for 
the diminution of the swelling nor necessity for the removal of bandages. 

2. It allows a positive diagnosis to be made, at the same time reveal- 
ing the exact nature of the injury. 

The variety of fracture, whether oblique, transverse, comminuted or 
fissured. 

Its exact seat and extent, whether of the anatomical or surgical 
neck or shaft, whether intra- or extra- capsular, simple, complete, or 
incomplete, green -stick or intra-articular, etc. 

The number of fragments, their size, shape, position or location. 

The overlapping of the fragments, the exact amount and direction 
of displacement, and whether the fragments are in apposition or not, 
can only be ascertained before or after the reduction of the fracture. 

3. It allows of its differential diagnosis from the following condi- 
tions : dislocation, epiphyseal separation and displacement ; diseases of 
bones and joints. 

The differentiation of a fracture from a dislocation is often difficult, 
because the great effusion or swelling around the joint will quickly 
produce marked deformity. Because immediate reduction is necessary, 
an early diagnosis is an important matter. 

When an injury occurs in the vicinity of a joint, especially in chil- 
dren, the epiphyseal condition will at once attract attention. The 
epiphyseal separation or displacement is most important, but is easily 



252 ELECTEO-THERAPEUTICS. 

solved by the skiagraph. In differentiating epiphyseal separation from 
fracture, the patient's age must be considered, the average date of union 
varying in each individual. 

Fractures of the epiphyses and their displacements can also be 
differentiated from fractures of other portions of the bone. Fragments 
of the epiphyses may float in the joint and simulate fracture or dislo- 
cation. 

B. DISEASES OF BOXES AND JOINTS. 

The normal bone appears on the skiagram with its characteristic 
texture. When any alteration, as increased density, is shown, it is due 
either to an increased blood supply (as in osteitis or periostitis) or to 
hypertrophy of the osseous structure, and the beginning of an inflamma- 
tory process. Later, when the caseation or absorption takes place, 
the bone will appear more translucent than normal. This shadow can 
readily be differentiated from that of a fracture. 

Osteitis and periostitis are differentiated from fracture and callus with 
great facility. 

Tumors of bones can be differentiated from suspected fractures or 
formations of callus, especially in cases of impacted fractures of the neck 
of the femur ; for the latter, being undiagnosed, and exuberant callus 
forming, may be mistaken for a tumor. 

Exostoses of bones, which may occur either after fracture or in- 
jury to the epiphyses, can be differentiated from a displaced fragment 
of fractured bone. Exostoses, however, may be congenital, when not 
infrequently they are found to be multiple. 

The differentiation between coxa vara, fracture of the neck of the 
femur, coxalgia, and arthritis of the hip-joint, is of great value to the 
surgeon. 

Diseases of Joints. In cases of synovitis, tenosynovitis, arthralgia, 
rheumatic conditions, bursitis, epiphysitis, and tuberculous arthritis 
following injuries, the X-rays will prove most valuable in clearing up the 
diagnosis by differentiating between fractures and diseases or injuries 
of the soft tissues. 

By means of the X-rays we are enabled to show clearly the bones, the 
muscles, and tendons (such as tendo Achillis, and ligamentum patellae, 
tendo-quadriceps, etc. ) ; but often we experience much difficulty in de- 
tecting with the aid of the X-rays the injuries to these soft structures in 
all parts of the human body. In children the X-rays show the capsule 
and hamstring tendons in the knee-joints, etc. 

Sprains and strains caused by a twisting of the joint, which result in 
a rupture of some or all of the ligaments or tendons, are conditions always 
difficult to diagnose. In those suspected cases when the part is examined 



THE CLINICAL APPLICATIONS. 253 

with the X-rays it is noticed that there is no fracture, and by exclusion 
we are justified in saying that a sprain exists. If the periosteum is torn 
off by a ligament or tendon, it will be observed under certain favor- 
able conditions. (See Figs. 133 and 145. ) 

In many instances I have been able to see on the negative the ten- 
dons and ligaments in the ankle-joint, and in the lateral view also those 
of the knee-joint, etc., especially when a soft negative was obtained. In 
children the negative should be "soft" and full of details ; a short 
exposure with a high-vacuum tube should be the rule. 

C. VALUE IN THE TREATMENT OF FRACTURES. 

The X-ray diagnosis during and after the treatment of fractures is 
invaluable, assisting the surgeon in approximating the fragments, which 
can be accomplished by observing the process with a fluoroscope ; thus a 
cast can be applied at once without disturbing the reduced fragments. 
After the permanent dressing or cast has been applied, another fluoro- 
scopic or skiagraphic examination will reassure him of the correctness of 
the position of the fragments. 

As a fracture is readily diagnosed by the X-rays, it is no longer 
necessary to delay treatment until the swelling and effusion subside, thus 
endangering the integrity of the joint. 

The frequency of deformities following fractures has been steadily 
decreasing since the introduction of the X-rays. 

In suturing or wiring the great advantage gained from the rays is 
that the operator is informed whether or not the suturing material is 
remaining intact. 

D. CALLUS FORMATION. 

In the first stage of callus formation the X-rays reveal nothing. 
About the twelfth or fifteenth day, it manifests itself as a cloudy mass at 
the ends of the fragments, and, as calcareous salts are deposited, the X-rays 
show the presence of a dauker substance. The time required to produce 
this phenomenon depends upon the variety of fracture, the age of the 
individual suffering from the accident, etc. 

Duration of Callus Formation. This is variable, in small bones the 
time required is brief; thus the metatarsal bones manifest a cloudy 
appearance about the end of the second week. About the second month 
the rays show the callus formation to be firm and definite. It is fre- 
quently difficult to see the shadow of callus ; because the latter is liable to 
be superimposed by the shadow of the bones. The shape of the callus is 
fusiform and encircles the ends of the fragments. 

The Varieties of Callus. In many cases the bones are united firmly 
and strongly several months after the accident, nevertheless the X-rays 
may fail to reveal these conditions. On the contrary, callus may be 



254 ELECTEO-THEEAPEUTICS. 

thrown out and yet the parts may not be firmly united, as in an oblique 
fracture of the tibia and fibula. This may arise from the callus being 
too deficient in quantity to give a shadow on the plate. 

Perfect Apposition. If there is good apposition at the ends of the 
fragments, especially of the long bones, the callus is not easily discovered, 
being overlapped by the shadow of the bones ; but a careful examination 
will divulge the callus, encircling and forming a faint fusiform shadow, 
in addition to the compact osseous tissue. 

Slight Overlapping. In cases of displacement or slight overlapping, 
the space between the fragments will be a light area, but as callus 
is deposited the space will become gradually lighter on the negative, 
depending upon the thickness of the callus thrown out. 

False Joint. If callus does not fill the space between the fragments, 
the bone at the seat of fracture remains movable and the condition of a 
false joint is produced. This is the result of a fibrous and not of a bony 
union. It is of great importance to be able to differentiate true from false 
union. 

Fractures with Extensive Displacements. When the displacement is 
so extensive (2-3 cm.) that the ends of the fragments do not come in 
apposition, lateral union occurs, which requires several years for its com- 
pletion and at best does not result in a very strong coaptation of the 
fragments. 

Age. Because of the vitality of the osseous system and the perios- 
teum, the formation of callus in children and the adolescent is more rapid 
than in the adult and the aged. This ready deposit of callus must not 
be mistaken for periostitis the result of the traumatism. 

Structure of Callus. When the fracture is old and vicious union 
has occurred, the X-rays may reveal a partial or complete absence of the 
bony structure, the texture and trabeculse having suffered a complete 
change. Care should be exercised not to confound this osseous change 
with osteo-myelitis or some other bone disease. 

III. Fractures and Dislocations of the Upper Extremity. 
THE HAND. 

Fluoroscopic Examination. The fluoroscopic examination of the hand 
is satisfactory only when no skiagraph can be taken. 

In the examination for fracture, the patient should be seated and all 
bandages and splints removed. In the presence of a wound, avoid all 
danger of sepsis by covering it with aseptic gauze. Extend the hand, 
place it against the screen, 20 inches from the Crookes tube, the rays are 
to fall perpendicularly. The right hand of the operator grasps the handle 
of the fluoroscope, with his left he manipulates the hand of the patient, 
gently pressing and rotating the suspected parts in order to view at 
all angles the injured part. This pressure in cases of green-stick and 




FIG. 116D. WRIST-JOINT (antero-posterior view). Plate, 6*4 in. x 8V in. (16x21 cm.V showing the 
carpal bones, and the lower ends of the radius and ulna. 




FIG. 116E. Antero-posterior views of both wrist-joints. 



THE CLINICAL APPLICATIONS. 255 

impacted fracture is especially necessary, in order to produce marked 
separation of the fragments, so as to be able to view the disturbance of 
texture and the irregular contour of the periosteum. 

In order to determine the direction of the displacement in disloca- 
tion, the phalanges, carpals, and metacarpals must be examined in the 
lateral, antero -posterior, and oblique positions. The backward disloca- 
tion of the first phalanx of the thumb is of special interest, because there 
is usually some difficulty in its reduction. (Fig. 117.) Of course the 
normal hand must first be studied. (Fig. 118.) 

Skiagraphic Examination. Secure a sensitive plate of sufficient size 
to include the entire hand. The arm and elbow should rest upon the 
table, to obviate any possible movement or tremor. Place a sheet of 
blotting paper or celluloid between the hand and the plate, to prevent 
moisture affecting the gelatine coat of the latter. The tube should 
now be placed 20 inches (50 cm.) above the hand, directly over the 
middle of the third metacarpal bone. Expose the plate from 3 to 5 
seconds. In skiagraphing the phalanges, it is necessary to take both a 
lateral and an antero-posterior view. Fracture of the scaphoid is shown 
in Fig. 119. 

Lateral and oblique fractures of any of the phalanges may be readily 
skiagraphed by placing the fingers separately in a lateral position upon 
the plate. Unfortunately carpal and metacarpal bones cannot be skia- 
graphed separately. The fluoroscope usually suffices in the examina- 
tion of the phalanges, but for the carpal and metacarpal bones more 
satisfactory results are obtained with the skiagraph. If there is much 
swelling of the palmar surface of the hand, place that member in the 
dorsal position upon the plate, when the shadow of the bone will appear 
much clearer. 

THE WRIST-JOINT. 

Fluoroscopic Examination. In examining the wrist-joint, follow the 
directions given for the hand ; manipulate the part gently, so as not to 
aggravate the injury. This examination should be conducted before 
splints or casts are applied. Much assistance can be rendered the 
surgeon if the process of reduction is watched through a fluoroscope. 

Skiagraphic Examination. The wrist-joint should be skiagraphed in 
the supine, prone, and the lateral positions both before and after reduc- 
tion and also before removing the cast. Place both the hands upon the 
plate for comparison. A small weight is placed upon the hand, or the 
arm is strapped to a board, to prevent tremors. In the lateral position 
the tremor can be avoided by the patient grasping a book or other small 
object. 

Lower End of the Radius and Ulna. An epiphyseal separation at the 
lower end of the radius may be mistaken for a Colics' s fracture. (Fig. 124.) 



256 ELECTKO-THERAPEUTICS. 

It must be borne in mind that the epiphysis commences to ossify about 
the end of the second year of life, and unites with the shaft at about 
the nineteenth or twentieth. Vertical fracture of the epiphysis is rare. 

The difficulty in detecting this fracture is due to a wrong position of 
the tube, in consequence of which its rays not falling perpendicularly do 
not traverse between the fragments ; or the shadows of the fragments may 
superimpose, and thus obliterate the dark line on the negative. 

Though dislocations at the wrist-joint were regarded by the older 
writers as of infrequent occurrence, the advancements made in diagnosis 
and the discovery of the X-rays prove them to be of much greater fre- 
quency than was formerly supposed. These dislocations may be back- 
ward, forward, or lateral, and may occur independently of fracture of 
the radius or ulna. 

THE FOREARM. 

A fluoroscopic examination of the forearm is conducted in the same 
manner as for the wrist-joint. 

A skiagraphic examination can be taken while the arm is in either 
the supine, prone, or lateral position. The plate should be 8 x 10 inches 
(20x25 cm.), the time of exposure from 5 to 10 seconds. 

Fractures of the middle third of the radius and ulna in children are 
discerned with difficulty by the fluoroscope, being usually the so-called 
green-stick fractures. A skiagraph is preferable. (Fig. 125.) 

In fractures of the radius and ulna, if the two lines of injury are 
near each other, the subsequent callus formation may bring these 
bones together, thus producing a synostosis, which will interfere with 
rotation of the arm. The X-rays will indicate the amount of callus 
thrown out. 

In Colles's fracture a skiagraph taken in the antero-posterior posi- 
tion may not show the fracture, or should the fracture appear the degree 
of displacement of the lower fragment may not show at all. This will 
necessitate a skiagraph taken in the lateral positions ; i. e., the ulnar or 
radial sides being in contact with the plate. (Figs. 120, 121.) 

In the oblique type of Colles's fracture the line of dissolution often 
includes a chipping off of the styloid process of the radius. 

Fracture of the styloid process of the radius may be found inde- 
pendent of (Figs. 122, 123), or in connection with, Colles's fracture. 
Often the anterior border of the radius is fractured, producing subluxa- 
tiou of the wrist. 

Multiple fracture, especially that form known as the Y-fracture, is 
more common than is usually supposed. 

The supine or prone position of the wrist may show in the skiagram 
either lateral displacement, transverse, oblique, or Y-fracture, and fissure 
or fracture of the styloid process of the radius. 





FIG. 117. Inward dislocation of the first phalanx of the thumb. (Case of Dr. G. E. Shoemaker.) 














FIG. 118. The normal hand, taken with high-vacuum tube. 




FIG. 119. Fracture of the scaphoid, 1, 1. 




FIG. 120. FIG. 121. 

COLLES'S FRACTURE. 
(Antero-posterior view.) (Lateral view.) 

Left picture, taken in the prone position, shows, at F >- and F, a transverse fracture of the 

radius and a green-stick fracture of the ulna. E > and E >- are the ununited epiphyses. The 

right-hand picture is the same, taken in a lateral position. (Case of Dr. Franklin Brady.) 





FIG. 122. Fracture of styloid process of the 
ulna (supine position, hand slightly abducted). 



FIG. 123. The same, in the prone position, 
which does not show the fracture (arrow 5). 




FIG. 124. TYPICAL COLLES'S FRACTURE. The bones appear white, as seen on the negative: 
1, scaphoid ; 2, semilunar ; 3, cuneiform ; 4, pisiform ; 5, unciform ; 6, os magnum ; 7, trapezoid ; 
8, trapezium. 




FIG. 124A. ELBOW-JOINT (lateral view). Patient sits at the end of table and with the uninjured hand 
grasps the table, the elbow resting on the plate, which is placed on a V-shaped head-rest. 




FIG. 124B. ELBOW-JOINT (antero-posterior view). Plate, 8 in. x 10 in. (20 x 25 cm.). Patient grips the 
holder while the olecranon process rests on the photographic plate. If the patient can extend his 
elbow (and often this is the resulting position in cases of injury to this joint) it is better to rest the 
hand on a block of wood or a book. 




FIG. 124C. WRIST-JOINT (lateral view). In either of these positions the palmar or dorsal, ulnar or radial 
sides may be placed in contact with the photographic plate. 



THE CLINICAL APPLICATIONS. 257 

Occasionally the styloid process carries with it when fractured a 
part of the dorsal border of the radius ; this is known as Barton's frac- 
ture. Colics' s fracture is frequently associated with fractures of the 
styloid process of the ulna accompanied by rupture of the triangular 
fibro-cartilage. 

THE ELBOW-JOINT. 

Fluoroscopic Examination. It is very unsatisfactory to examine the 
elbow in the antero-posterior position with the ordinary fluoroscope, as 
the curvature of the part prevents a close approximation of the screen. 
To meet this difficulty it is necessary to employ a small tubular fluoro- 
scope which fits snugly the anterior surface of the joint. A disadvan- 
tage of this fluoroscope is the small area brought into view. To obviate 
this the author has devised a flexible fluoroscope which, when properly 
used, will bring all the parts into view. 

The lateral position is by far the most convenient one in which to 
examine injuries of the elbow-joint with the fluoroscope. The joint 
should be viewed from the internal, external, and lateral positions. 

SJciagraphic Examination of the Elbow. Skiagraph the elbow either 
in the anterior, posterior, or antero-posterior position. The forearm 
should be well extended and placed in the supine position. The sensi- 
tive plate 8x10 inches, (20x25 cm.) is placed under the olecranon 
process of the ulna, with the tube held at a distance of from 12 to 16 
inches (30 to 40 cm.) above the joint. 

The elbow-joint is best shown in two views, the antero-posterior and 
the lateral. 

To skiagraph the elbow in the postero-anterior position, place the 
patient in the ventral recumbent posture, with the arm extended by his 
side. Place a small plate under the joint, remembering that it should be 
as near the bones as possible. 

A sensitive film can be placed in the flexure of the elbow-joint and 
the tube beneath the table ; a convex block of wood, also conforming 
to the contour of the flexure of the joint, will hold the film in position. 

In the lateral position the plate should be placed either under the 
internal surface of the elbow with the tube above the joint, or over the 
external surface with the tube beneath the table, the former being prefer- 
able. In both of the above methods, the elbow should be flexed and 
brought on a level with the shoulder of that side. 

To properly interpret the shadows, a normal corresponding joint in 
the same individual must first be carefully studied; especially is this 
the case with children. In the antero-posterior position, we notice the 
shadow of the olecranon process clearly visible and superimposed upon 
the shadow of the sigmoid fossa. Light shadows are seen between the 
articulating surfaces of the hunierus and ulna. 
17 



258 ELECTKO-THEKAPEUTICS. 

A skiagram of the elbow in the antero-posterior position always 
shows a light horizontal shadow between the internal condyle of the hu- 
merus and the coronoid process of the ulna, which has often deceived the 
inexperienced into diagnosing a fracture of the olecranon. Fig. 126 shows 
the lighter portion extending inward between 10 and 7, toward 11. This 
shadow is in reality that of the olecranon process of the ulna, and is 
deceptive, because it is bounded by heavier shadows, which are cast by 
the humerus and olecranon on one side, and by the coronoid and the 
olecranon processes on the other. 

Fractures of the head or neck of the radius are of rare occurrence. 
(Fig. 126.) 

Separation of the epiphyses is extremely rare. (Fig. 127.) It is 
convenient to know that ossification begins about the sixth year, and 
union with the diaphysis occurs about the sixteenth or seventeenth year. 

Fractures of the upper third of ulna, with dislocation of the head of 
the radius, are skiagraphed by lateral exposure. (Fig. 128. ) 

In longitudinal fracture of the upper end of the ulna, the lateral 
position will not reveal the fracture, but it must be skiagraphed in the 
antero-posterior position. 

In order to separate the fragments, when the fracture is in close 
proximity to the insertion of the brachialis anticus, the arm should be 
well extended during the examination. 

Dislocation of the Elbow-Joint. For dislocations of the elbow-joint a 
lateral view should be taken with fluoroscopic and skiagniphic examina- 
tions. In children, this dislocation may simulate epiphyseal separation. 
Supra-condyloid fracture, partial fracture of the internal epicondyle, and 
partial detachment of the external condyle of the humerus, are well 
shown in Figs. 139, 130, 131, and 132. Detachment of the supinator 
longus muscle, simulating a fracture of the humerus and epiphysitis of 
the humeral head, at first thought to be a fracture, are depicted in Figs. 
133, 134, and 135. 

THE MIDDLE THIRD OF THE HUMERUS. 

Fluoroscopic and skiagraphic examinations readily reveal, from all 
sides, fractures of the middle third of the humerus. 

THE SHOULDER- JOINT AND ITS VICINITY. 

On account of the immediate swelling of the part, examination is 
often rendered very difficult. 

Fluoroscopic Examination. If the patient is a child or a thin person, 
this method of examination will be satisfactory. 

Should one suspect fracture with dislocation, it is preferable to 
take a skiagram, as it requires less disturbance of the parts. The 
examination is made in the antero-posterior position. 




FIG. 124D. SHOULDER-JOINT (dorsal decubitus view). Patient lies on table and a plate, 10 in. x 12 in 
(25 x 30 cm.) is placed under the shoulder. 




FIG. 124E. SHOULDER-JOINT (erect dorsal view). Patient sits on a stool at the end of the table. 
The lower end of the table is raised and adjusted. Same sized plate is employed. 




Fio. 124F. SHOULDER-JOINT (posterior-anterior view). Patient lies in ventral recumbent position, 
shoulder resting on a V-shaped board. This position can be employed in radiographing coracoid 
process and fractures of the clavicle. 



THE CLINICAL APPLICATIONS. 259 

Fractures of the surgical neck of the humerus are quite common 
(Fig. 136), while fractures of the anatomical neck are very rare. 

In skiagraphing the shoulder-joint, in order to avoid erroneous inter- 
pretations, the operator should always bear in mind that the epiphysis 
and diaphysis do not unite until the twentieth year. 

SJciagraphic Examination. The patient is placed in the dorsal recum- 
bent posture, the head being supported by a low pillow, and the un- 
bandaged arm is extended to an angle of 35, and is immobilized by 
employing a sand-bag or small weight. 

In corpulent individuals the head of the humerus may be too distant 
from the sensitive plate. This may be remedied by simply tilting the 
patient to that side, or by raising the uninjured shoulder on a pillow. 
The rays should be directed over the lower border of the glenoid cavity. 

In viewing from the anterior position, the patient may lie either on 
his abdomen or on his back. When the patient assumes the former 
position, the tube is placed over the spiuous process of the scapula, and 
the plate rests on the table, under the joint. In the dorsal recumbent 
position the tube is placed under the table, and the patient may rest 
either in the dorsal decubitus or semi-recumbent position. I put the 
plate in an adjustable plate-holder, which prevents it from coming in con- 
tact with the patient. The rays should be applied only during the period 
in which the patient holds his breath, after a full inspiration or expira- 
tion. These intermittent exposures should be repeated 4 or 5 times. 
This method prevents the blurred effects which one sees occasionally. 

Dislocations or Subluxations of the Shoulder. In these classes of cases 
there is likelihood of wrong interpretation of the skiagraphed part, as 
different positions of the tube and arm will give varying relations of the 
humeral head to the glenoid cavity. In order to guard against this error, 
a large plate should be used on both shoulders, and the parts skiagraphed 
simultaneously, by placing the tube on the median line, and maintaining 
both shoulders and arms in precisely the same position. Instead of 
using one large plate, we may employ two plates placed together. 

The acromio-clavicular space, being cartilaginous, appears as though 
a fracture or separation existed. Sometimes this light area is exaggerated 
on account of the faulty or oblique position of the shoulder or part. 

The oblique ridge separating the head from the anatomical neck 
often shows a white line on the negative. A depression where the 
spinatus muscle is attached may also be seen on the plate. Fig. 137 
shows a fracture of the acromion process. 

THE CLAVICLE. 

Fractures of the clavicle occur mostly in children, yet they may 
happen at any age. (Fig. 138.) Skiagraphic examinations are best 
obtained by taking either anterior or posterior views. Dislocation of 
the scapular end and other varieties can be readily discerned. 



260 ELECTRO-THERAPEUTICS. 

THE SCAPULA. 

Fracture of the scapula is best skiagraphed in the dorsal recumbent 
posture. The coracoid process is best skiagraphed with the patient on 
his abdomen ; the better method is to place the tube in such a position 
that the rays will pass through the axillary space, the plate being 
fastened over the clavicle, the coracoid, and acromial processes. 

Always endeavor to throw the shadow of the process under the clear 
space of the clavicle, and not over the neck of scapula. 

FRACTURES OF THE SKULL. 

Many difficulties are met in skiagraphing fractures of the skull, 
owing to the superimposition of the shadows of the bony walls surround- 
ing the part under examination, and the difficulty in bringing the plate in 
proper apposition to the curved outline of the skull cap. Fluoroscopic 
examinations are satisfactory in the thin skulls of young children. Skia- 
graphs can be taken in the lateral, the fronto-occipital, and the occipto- 
frontal positions, but the lateral view affords greater detail of structure 
and offers a clearer field. 

Fissured fracture of the base defies detection, because the line of 
fracture is inaccessible in any position in which the tube may be placed. 
Any change in the contour of the inner or outer tables of the skull or the 
presence of the formation of callus, can be brought out by placing the 
tube and plate in exactly the right position, which can be determined only 
by constant practice. 

IV. Fractures and Dislocations of the Lower Extremity. 
THE FOOT. 

Fractures. Fractures of the phalanges of the foot are of the com- 
minuted or splintered type. 

Fractures of the metatarsal bones, which were formerly thought to be 
extremely rare, have been shown by the X-rays to be of common occur- 
rence. (Figs. 139 and 140.) The so-called "swelling" of the feet is 
often due to fracture of one or more metatarsal bones. The first and fifth 
of these bones are most frequently broken, the resulting fracture being of 
the compound type. 

Fractures of the astragalus and os calcis are not infrequent, the force 
travelling through the body or neck. This injury is often associated with 
a separation or a dislocation of one or the other fragment. Fracture of 
the os calcis may involve the body of the bone or one of its processes, and 
is frequently comminuted. Fractures of the astragalus and os calcis can 
readily be seen on the screen if there is sufficient separation of the 
fragments. The lateral view is always preferable. 

Fractures of the phalanges and metatarsal bones may be disclosed by 
a fluoroscopic examination. Skiagrams of these fractures may be made 




FIG. 125. Green-stick fracture of the ulna, B, with a transverse fracture of the radius, D. 
A and C arc the epiphyscs. 




FIG. 126. Fracture of the neck of the radius, 8. 




FIG. 127. EPIPHYSEAL SEPARATION AND DISPLACEMENT OF THE LOWER END or THE HUMERUS. 
The condylesS, 4, remain r.t their normal positions, the diaphysis having suffered a lateral displace- 
ment. The dotted line indicates the normal position that the diaphysis should occupy. 




FIG. 128. Fracture of the ulna and displacement of the head of the radir.s, 8. 




FIG. 129. Supracondyloid fracture of the humerus. 




FIG. 130. Fracture of part of the internal eplcondyle after forcible reduction for dislocation. 




FIG. 131. Detachment of a portion of the external condyle of the humerus, antero-posterior view. 

FIG. 132. The same, lateral view. 3, inner condyle ; 4, olecranon fossa ; 5, external condyle ; 
6, olecranon process; 7, coronoid process of the ulna; 8, centre of ossification of the head of the 
radius. (Case of Dr. Franklin Brady.) 




FIG. 133. DETACHMENT OF THE SVPINATOR Loxors MUSCLE, INDICATED BY THE ARROW. The injury 
was thought to be a fracture prior to X-ray examination. (Case of Dr. H. C. Kellner.) 





FIG. 134. EPIPHYSITIS OF THE HUMERAL HEAD. 



FIG. 135. THE CORRESPONDING NORMAL SIDE. 



Epiphysitis of the head of the humerus, diagnosed as a fracture. 3, internal epicondyle ; 
4, olecranon fossa ; 5, external epicondyle ; 6, olecranon process ; 7, coronoid process of the ulna ; 
8, head of the radius ; 9, tuberosity of the radius ; 10-11, trochlea ; 11, centre of ossification of the 
capitellum. 




FIG. L&. Subluxation of the shoulder-joint, L 

surgical neck. 



; P > is a fracture of the 




FIG. 137. Fracture of the acromion process, > F. (Case of Dr. C. II. Burr.) 




FIG. 138. Fracture of the acromial end of the clavicle. (Case of Dr. W. L. Rodman. ) 




FIG. 139. Fractures of the 1st, 2d, 3d and )th metatarsal bones and of the 1st phalanx 

of the great toe. 




?IG. 139A. FEET (dorsal view). Patient sits on the table at the opening. The plate is placed overa 
box. with the tube in the median line. 




FIG. 139B. ANKLE-JOINT (lateral view) .Plate 6> in. x 8% in. (16 x 21 cm.). This will include the ends 
of the tibia and fibula, astragalus, os calcis, and tarsal bones. 




FIG. 139C. ANKLE- JOIST (anteroposterior view). A leaf of the table is raised and a board is placed 
to cover the opening, and for both ankles a plate 10 in. x 12 in. (25 x 30 cm.) is employed; the diaphragm 
Is fixed over the median line; for sake of comparison both feet are tied to the upright leaf. When one 
ankle is to be radiographed bring the compression diaphragm close to that joint. 

TARSUS, METATARSUS AND PHALANGES (dorsal view). These can be radiographed by placing plate 
in a vertical position against the plantar surface and turning the compression diaphragm at right 
diigles to the plate or foot. 




FIG. 139D. KNEE-JOINT (lateral view). Plate Sin. x 10 in. (20 x 25 cm.), the leg being slightly flexed, 
in order to lessen any tremor or motion. 



THE CLINICAL APPLICATIONS. 261 

in a number of positions. In the anterior-posterior position the patient 
occupies a high stool with a back rest, which affords greater comfort and 
lessens the possibility of movement. The foot should be placed on a 
small supporting bench which may serve as a holder for the sensitive 
plate as well. 

The foot is extended by gradually moving the bench from the stool, 
the patient in the meantime being instructed to keep the sole of the foot 
evenly upon its top. In skiagraphing a "partial" lateral view the 
rays from the tube should fall more or less obliquely, thus preventing a 
superimposition of the metatarsal shadows. 

Skiagraphy of the tarsal bones is more difficult. The astragalus may 
be successfully skiagraphed in an antero-posterior view, by placing the 
tube anteriorly at the upper angle of the foot and the sensitive plate 
posteriorly, plantar or dorsal. Put both feet close together upon two 
separate 8 x 10 inch (20 x 25 cm. ) plates, with the tube in the centre. The 
tarsal articulation can be best skiagraphed by placing the plate against 
the dorsum of the foot and allowing the rays to penetrate through the 
plantar surface. 

Dislocations. Phalangeal dislocations of the foot closely correspond 
to those of the hand, but are of much less frequent occurrence. 

Dislocation of the metatarsal bones at the tarso-metatarsal articula- 
tion, usually occurs as a complete displacement involving several or all of 
the metatarsal bones on the dorsum of the foot. Plantar dislocations are 
very rare. 

The technic in dislocations is practically the same as has been 
discussed under fractures. 

THE ANKLE-JOINT AND CONTIGUOUS STRUCTURES. 

Fractures. Fractures of the ankle-joint involve the tibia, fibula, and 
tarsal bones, either alone or in combination. For all practical purposes 
they should be divided into two groups, dislocation-fracture and sprain- 
fracture. 

A supramalleolar fracture of the tibia and fibula is best skiagraphed 
autero-posteriorly. Skiagrams of typical Pott's fracture show a trans- 
verse or oblique line of injury in the lower third of the fibula, with frac- 
ture of the malleolar processes of the tibia. (Fig. 141.) A skiagram is 
best made by placing the patient in a recumbent or semi-recumbent posi- 
tion. The sensitive plate, 8x10 inches (20x25 cm.), should be placed 
directly under the seat of the injury, as low as the os calcis, the leg being 
slightly rotated inward to prevent superimposition of the shadows of the 
tibia and fibula. The tube should be about 20 inches (50 cm.) distant 
from the plate. The time of exposure varies between 10 and 20 seconds. 
When the fracture is longitudinal, without displacement, the antero-pos- 
terior view may fail to reveal the presence of fracture ; in such a case, it 



262 ELECTRO-THERAPEUTICS. 

is imperative that a lateral view should be taken, with the suspected 
side next to the plate. A fracture box should be employed to secure 
immobilization. 

Epiphyseal separation and malleolar and supramalleolar fractures 
must not be confounded with Pott's fracture. 

Dislocations of the ankle present nothing characteristic and there- 
fore require no special technic. They should be examined in both 
positions. 

THE LEG (MIDDLE THIRD). (Figs. 142, 143.) 

Fractures. When making antero-posterior and lateral skiagrams in 
this region, prevent the shadow of the tibia superimposing upon that of 
the fibula, or vice versa. 

THE KNEE-JOINT. 

Fractures. Complete transverse fracture of the tibia in its upper 
third, fracture of the tuberosity, and traumatic epiphyseal separation of 
the upper end of the tibia, are readily discerned by the X-rays. 

The knee-joint should be examined from two views, either the antero- 
posterior or the lateral. A fluoroscopic examination of the knee-joint is 
rather unsatisfactory except in ankylosis. Gliding movements of the 
various ligaments and patella may be studied, and severed ligaments can 
often be detected. In osseous ankylosis the articular plane of the knee is 
obliterated, while in the fibrous form there is usually no such obliteration. 

In making antero-posterior skiagrams, have the patient on his 
back, with the head and chest elevated, the extremity of the foot fixed 
resting upon an extension of the operating table, or tied to fracture box. 
A sensitive plate 8x10 inches (20x25 cm.) is placed against the posterior 
aspect of the knee-joint, with the tube directly over the patella. The 
shadow of the patella is usually very faintly superimposed upon that pro- 
duced by the lower end of the femur. The patellar shadow is increased 
in density if the plate is placed in front of the patella and close to it, the 
rays being allowed to penetrate from behind. In making lateral skia- 
grams the patient should lie upon the injured side with the fractured 
joint slightly flexed, the other leg should be extended or fully flexed so as 
not to interfere with passage of the rays. Detachment of the tubercle of 
the tibia is shown in Fig. 145. 

Fractures of the Patella (Fig. 144). In transverse fracture of the pa- 
tella, the lateral fluoroscopic view shows the separation of the fragments. 
Stellate and fissured fractures can only be shown by a skiagraph taken in 
the postero-anterior position. The patient should lie face down, with the 
tube behind the joint and the plate under the patella. The sesamoid 
bones give distinct shadows and floating or loose bodies are often detected. 
Detached cartilages are very difficult (and often impossible) to skiagraph. 




FIG. 139E. BOTH KNEE-JOINTS (antero-posterior view ). Plate 11 in. x 14 in. (26 x 35 cm. ) ; the foot is 
vertically placed, the plate extending from the lower one-third of femur down. Both feet are tied 
and the compression diaphram is removed. Tube at a distance of 25 inches (75cm.) and points just 
below the patella on the median line. The shafts of the tibia and fibula can be radiographed in a 
like manner. 




FIG. 139F. PATELLA ('posterior-anterior view). The patient assumes a ventral position, thus the 
patella comes in close contact with the plate, producing a very clear picture. Stellate fractures can 
be seen only in this position. 




FIG. 139G. HIP-JOINT (antero-posterior view). Raise the leaf at the end of the table, place a board 
to cover the opening, and with the patient in a dorsal decubitus jxjsition use a plate 10 in. x 12 in. (25 x 
30 cm.) extending from the crest of the ilium, and two inches out from the external surface of the hip 
(the centre of the diaphragm being just over to Poupart's ligament). Both feet should rest, if possible, 
against the upright board and be tied, allowing the position of the foot on the injured side to resume 
its inverted or everted characteristic position. Of course, in some injured cases this position may be 
extremely painful and difficult. 




FIG. 139H. BOTH HIPS (antero-posterior view). Patient lies down as above. Plate 14 in. x 27 in. 
(35 x 42 cm.) is placed in a horizontal position. The compression diaphragm is removed and the tube 
is raised to a height of 25 inches (65 cm.), the anode pointing over the symphysis pubis (median line). 



THE CLINICAL APPLICATIONS. 263 

THE FEMUR (MIDDLE AND LOWER THIRDS). 

Fractures. Fractures of the shaft of the femur are common. In 
children the injury is usually transverse with little or no displacement, 
while in adults it is usually oblique with much displacement. In making 
skiagrams of the shaft, two plates, in exactly opposite directions, should 
be taken. Fractures of the lower third of the femur are easily diagnosed 
by the X-rays. 

THE HIP-JOINT. 

Fractures. Fractures of the upper end of the femur are divided as 
follows : (1) intra-capsular, (2) epiphyseal separation, (3) extra-capsular, 
(4) fracture of the trochanters, (5) isolated fracture of the trochanter 
major, and (6) fracture of the upper portion of the shaft immediately 
below the trochanters. 

Fluoroscopic examination of the hip-joint in children is usually 
satisfactory, but the thickness of the tissues makes it unsuited for adults. 
At best, skiagraphy of the adult hip-joint is troublesome, especially if the 
subject is very corpulent and the part painful. 

The technic is as follows : Have the patient fully extend the 
leg of the injured side. If this is impossible, place a pillow under the 
partially flexed knee. Place two superimposed plates, 10 x 12 inches 
(25 x 30 cm.) or 11 x 14 inches (28 x 35 cm.), under the hip, which 
should extend from the iliac crest and project two inches from the outer 
aspect of the leg. The tube should be placed directly over the head 
of the femur, and from 20 to 25 inches (50-63 cm.) from the plate. If 
the foot is inverted or everted from the injury, do not correct it. Guard 
against tremors by the use of a pillow, sand-bags, bandages, or 
suspended weights. 

It is often valuable to take both hip-joints at the same time for com- 
parison. For this employ either a large plate that will include the 
shadows of both hips or two smaller plates touching side by side. Adjust 
the tube to the median line at a distance of more than 20 or 25 inches 
(50-63 cm.), the anode pointing to the pubic symphysis, remembering 
that this position will require a longer exposure. It must never be for- 
gotten that certain positions of the foot will cause the neck of the femur 
to assume varying angles, shapes, and lengths to the acetabular cavity, and 
that the shape, distance, and position of the lesser trochanter will change 
its relation to the descending ramus of the pubis. To convince others 
of the correct interpretation of the negative, employ as a confirmatory 
measure a simultaneous skiagraph of both hip-joints, previously securely 
binding the feet and ankles in the vertical position, thus placing the 
necks of the femora in identical positions, or take another without tying 
the feet, and let the feet occupy their actual positions in order to show 
the difference. As very fine detail work i. e., the structural texture of 



264 ELECTRO-THERAPEUTICS. 

the femur must especially be brought out, it is apparent that, if this 
sharpness of definition is lacking, an impacted or fissured fracture might 
easily escape detection. 

In doubtful and obscure cases, advantage is gained by making another 
skiagram in the ventral position ; because of the thickness of this region, 
the time of exposure is lessened by using the intensifying screen, which 
sacrifices, however, the fine details. I therefore do not recommend it. 

Antero-posterior fractures of the acetabulum can readily be skia- 
graphed, but stellate fracture is extremely difficult to determine. Skia- 
grams of impacted fractures of the neck of the femur do not present the 
usual light lines. The fracture can, however, be diagnosed by the short- 
ening, and the slight irregularity in the size, shape, and .angle of the neck 
of the femur. 

The osseous ridge running between (intertrochanteric ridge) the tro- 
chanters posteriorly, usually gives a light line on the negative, which must 
not be mistaken for fracture. In the fracture at the base of the neck, 
the angle diminishes from the normal to 90 or less. An incomplete, 
intertrochanteric fracture is well shown in Fig. 146. 

Chemical intensification of a negative defines the osseous tissue more 
clearly, but as the detail of the soft structure is thereby diminished, a 
second exposure is preferable, if possible. 

A satisfactory negative should clearly differentiate the head and 
neck of the femur and the hip bones. If not sufficiently dense, the 
lines and shadows indicative of fracture will not be visible. The 
tendency in making these negatives is to over expose, but better results 
are obtained by using a tube of high penetrability, with an electrolytic 
interrupter. 

Dislocations. Congenital dislocation of the hip in children (Figs. 147 
and 148) can be well demonstrated by skiagrams, showing the presence or 
absence of the rim of the acetabular cavity, the depth of the acetabulum, 
the position, shape, and situation of the head of the femur. I have made 
studies of a series of cases, before reduction, after reduction through the 
cast, and after removal of the cast, in the service of Professor Adolf 
Lorenz during his recent visit to this country, and they proved to be very 
suitable and interesting from a stereo-skiagraphic stand-point. 

Pathological dislocations (Figs. 149 and 150) the result of tuber- 
culosis, osteo-arthritis, Charcot's disease, etc., are easily skiagraphed in 
the manner outlined under fractures. In pathological dislocations the 
head and neck of the bone are absent, as in cases of epiphysitis. 

THE Os INNOMINATA, SACRUM, AND COCCYX. 

Fractures. The clinical diagnosis of fracture of the pelvis can only 
be made when the separation of the bones is marked or when displace- 
ment is considerable. When only slight separation exists, the X-rays 




FIG. 140. FRACTURE OF THE MIDDLE OF THE FOURTH METATARSAL BONE. I, II, III are the meta- 
tarsal bones; A, 1st internal cuneiform; B, 2d middle cuneiform; C, 3d external cuneiform; D, 
cuboid bone ; E, scaphoid ; F, astragalus ; G, anterior process of the os calcis ; 1, 2, sesamoid bones. 




FIG. 141. POTT'S FRACTURE. F >-, F >-, fractures of both malleoli ; D > shows the in- 
ward dislocation of the tibia. The internal malleolus, at 2, should be in the dotted area, having 
become detached and left in the position marked 2 (white). 





FIG. 142. FRACTURE OF THE TIBIA AND 
FIBULA, TAKEN AT AN ANGLE BETWEEN THE 
ANTERO-POSTERIOR AND LATERAL POSI- 
TIONS. This skiagram fails to show any 
overlapping of the fragments of the fibula, 
but exhibits the presence of callus. 



FIG. 143. Lateral view of the same, reveal- 
ing a pronounced overlapping of the fragments. 
(Case of Dr. W. L. Rodman.) 




FIG. 144. Fracture of Ihe anterior portion of the patella. 







FIG. 145. Detachment of the tubercle of the tibia, result of a kick in a game of foot- ball, 
(Case of Dr. Carlos M. Desvernine.) 




FIG. 146. Incomplete intertrochanteric fracture. (Case of Dr. W. L. Rodman.) 




FIG. 147. CONGENITAL DISLOCATION OP THE HEAD OF THE LEFT FEMUR.!, lesser trochanter; 2, 
greater trochanter ; 3, head ; 4, neck ; 5, acetabulum. (Case of Dr. H. Augustus Wilson.) 




FIG. 148. CONGENITAL DISLOCATION OF BOTH HIPS. This skiagraph was taken by me after 
reduction by Dr. Adolf Lorenz of Vienna. 




FIG. 149. PATHOLOGICAL DISLOCATION OF LEFT HIP IN A CHILD OF Six YEARS. When one year 
old an abscess developed, which was incised and drained, and extension applied. Five years later the 
skiagraph, as shown above, revealed absorption of the femoral neck. On the normal side, N indicates 
the neck ; this is wanting on the affected side (X ) 1, lesser trochanter ; 2, greater trochanter ; 3, head 

of the femur ; N, neck of the femur ; 4 >-, epiphyseal line ; 5, acetabulum ; 7, iliac fossa ; 8, epiph- 

ysis between the ilium and ischium ; 9, pubic bone ; 10, obturator foramen ; 11, ischium ; 12, pubic 
arch; 14, ilio-pectineal line; 16 >- 16, sacro-iliac synchondrosis ; 17, crest of the ilium; 18, trans- 
verse process of the 5th lumbar vertebra ; 19, fecal matter surrounded by light area (gas) ; C, coccyx. 
(Case of Dr. James K. Young.) 




FIG. 150. A CASE OF PROBABLE INFANTILE PALSY. The patient's left femur (right side in the 
photograph) shows an absence of the neck, and also a transparent area at the dotted portion indicated 
at X. (Case of Dr. James K. Young. ) 



THE CLINICAL APPLICATIONS. 265 

are of great diagnostic aid, as the contour of these bones is very irregular 
and the rays must traverse great density of structure. Fractures of the 
pelvic bones are divided into those in which the individual parts are 
fractured and those in which the pelvic rim is broken. 

In skiagraphing the pelvis the patient must assume the ventral and 
dorsal decubitus positions. In a skiagraph of the sacro-coccygeal region 
the tube should be placed over the umbilicus so that the shadow of the 
pubic symphysis will not overlap the shadow of the sacrum or coccyx. 
The rectum should be emptied by an enema prior to the examination. 

The ilium, ischium' and the pubes can be skiagraphed in the above 
manner, with slight modifications in the relation of the tube, the part, 
and the plate. 

THE SPINAL COLUMN. 

For the sake of conveniently studying the spinal column, it is divided 
into the cervical, dorsal, and lumbar regions. 

The cervical region is best skiagraphed in lateral view. Complete 
fracture of the cervical vertebrae can easily be shown in skiagrams, but 
incomplete fracture is detected with great difficulty. In my experience 
I have found the fifth and sixth cervical vertebras are most frequently 
fractured. To demonstrate a fracture or dislocation, skiagrams should be 
taken in the lateral and the antero-posterior position. Recently I had 
two cases of old fracture-dislocations of the fifth cervical vertebra, and 
the patients are still alive. I have had four cases of fracture of the 
cervical vertebrae. 

Skiagrams of the dorsal region are somewhat indistinct, due to the 
superimposition of shadows cast by the liver, heart, sternum, and ribs. 
I have had four fractures of the second and eleventh dorsal vertebras. 
The best definition is obtained from the young and those of slender build. 
In thin persons antero-posterior dislocations may be shown by taking the 
skiagram in the lateral view. Of course distortion will be exaggerated 
on account of the distance between the plate and the vertebrae. 

Experience proves that the obstacles encountered in making skiagrams 
of the vertebral column are numerous. Thus, the peculiar anatomical ar- 
rangement in this locality, the projecting and irregular processes from each 
vertebra, and the impossibility of obtaining the desired relations between 
the tube, the part, and the plate, make this procedure a most difficult one. 
The dorsal decubitus should be selected for examining all regions of 
the spine ; but the tube should be placed at varying positions, and in 
this way the shadow, of the sternum will be lessened in the dorsal region. 
This technic answers for the dorsal vertebrae, but the upper six cervical 
should be taken in the lateral view. Only one region of the spine 
can be skiagraphed at a time. In order to obtain the intra-articular 
spaces clear and distinct, it must not be forgotten that the alimentary 



266 ELECTRO-THERAPEUTICS. 

canal should be well cleansed previously. The negative must be suffi- 
ciently dense to bring out strongly and sharply the shadow of each verte- 
bra with its processes. If this cannot be obtained, resort must be made 
to chemical intensification. 

The technic employed for the lumbar region is in every way identical 
with the technic employed in renal skiagraphy (vide). 

THE RIBS AND STERNUM. 

Fractures of the sternum are best examined by skiagraphing in the 
ventral position. The ribs can be examined by the fluoroscope in differ- 
ent directions. The dorsal and ventral views will reveal the fractures 
and even slight fissures, but difficulty is encountered at the angles of the 
ribs, because of the difficulty in approximating the plate, and the neces- 
sity of the rays traversing diagonally the thickness of the body, and 
because of the respiratory movements. 

The negative clearly reveals the presence of displacement. A slight 
fissured fracture may often escape detection. Care should be taken not to 
confuse the costo-sternal and costo- vertebral articulations with fractures. 
It must not be forgotten, in this connection, that the cartilages are trans- 
parent to the rays. Fracture of the ends of the floating ribs may be de- 
tected. The exposure must be short, and made preferably at the end of 
a prolonged inspiration, the patient holding his breath for five or ten 
seconds. Zinc-oxide adhesive plaster, if uniformly applied over the en- 
tire chest, immobilizes the part and aids the skiagrapher, but a few strips 
applied for this purpose may confuse the picture on the negative by 
casting shadows, in conjunction with those of the ribs. 

Do not mistake the various grooves or prominences in the ribs for a 
fracture. 

V. Diseases of the Osseous System. 

As the osseous system is largely composed of mineral matter (cal- 
cium phosphate), the X-rays in their passage must suffer a marked 
absorption and their progress meet with great obstruction, causing 
decreased oxidation on the plate, and offering white shadows on the 
negative, thus greatly facilitating its study. Some think that the rays 
throw merely a shadow or silhouette of the bone on the plate, but the 
fallacy of this view is apparent. In studying the photograph of the 
humerus, for example, we see the superimposition of various strata of 
different densities ; the compact portion appears denser than the medul- 
lary, because the rays in the former must traverse more osseous structure. 
In the medullary portion the negative gives a darker appearance, because 
the rays are only compelled to pass through two layers of bone, the 
medullary canal intervening. Ridges appear whiter, and fossae darker, 
than the medullary portion, due to increased density ; foramina? show 



THE CLIXICAL APPLICATIONS. 267 

as dark spots, while bony canals offer dark lines on the negative. Articu- 
lar cartilages being transparent to the rays, and likewise the epiphyses, 
the shadows cast will be dark. 

A. PATHOLOGICAL CONDITIONS. 

Any pathological condition either in the organic or inorganic con- 
stituents will offer a corresponding change in the shadow thrown ; the 
diseased portion of bone will cast a shadow lighter or darker than the 
surrounding healthy osseous tissue, and likewise of the same bone of the 
opposite side. In skiagraphing osseous tissue, care should be taken to 
ascertain the presence of diseased conditions of surrounding soft parts, 
such as an effusion, cyst, tumor, etc., as their presence might produce a 
dense shadow that could be interpreted as belonging to the bone. To 
corroborate the diagnosis, a skiagram of the corresponding part should 
be taken, with exactly the same technic, as difference in the position of 
the plate, the tube, and the part might cause a difference in the definition, 
shape, and size of the shadow produced. When possible, expose both 
parts simultaneously. 

Acute and Chronic Periostitis and Osteomyelitis. Periostitis is charac- 
terized by the presence of a fusiform thickening of the periosteum. 
This must not be mistaken for bony irregularities. 

Osteitis (osteo-myelitis) is marked by an increase in shadow density. 
(Figs. 151, 152.) Eight or ten days after the injury suppuration occurs, 
and about the twelfth day disintegration of bone takes place, resulting 
in the production of a lighter shadow. Later, the skiagraph of a 
sequestrum will be revealed. 

Tuberculosis of Bone. This affection is characterized by numerous 
white irregular spots which have a natural tendency to coalesce. The 
shadow cast will be lighter than that of the normal bone, because the 
rays traverse less density, due to caseation and fibrous tissue formation. 
(Fig. 153.) 

Syphilis of Bone. In syphilis of the bone, two conditions are en- 
countered, the occurrence of rarefaction or an absorption of the com- 
pact bony structure, and a sclerosis, with an increase in density of the 
bone affected. The infected gummatous portions of the bone cast a 
lighter shadow than does the normal bone. When eburnation occurs the 
shadow cast will be darker, but the density of the shadow will not be 
uniform, an irregular thickening encroaching upon the medullary canal 
being evidenced. In the adult this condition is differentiated with 
difficulty from the thickening resulting from a chronic osteitis and 
periostitis. (Fig. 154.) 

Hypertrophic deforming osteitis (Paget's disease) presents a hyper- 
trophy of the compact tissue, manifesting a very dense shadow. 

Leprosy. Among the various bone lesions, transparency of the 



268 ELECTEO-THEEAPEUTICS. 

digital phalanges is most frequent. This transparency is very pro- 
nounced in the distal phalanges, though it may be equally so in the 
others. 

Acromegaly. This affection may be more thoroughly understood by 
a careful investigation into the bony peculiarities of the skull. A great 
prominence of the external occipital protuberance, an irregular thick- 
ening of the cranial parietes, the over-development of the frontal sinuses 
and mental eminence, as well as the marked hypertrophy of the sella 
turcica, make this means of diagnosis of incalculable benefit. The 
shadows of the phalanges show the epiphyses to undergo an enormous 
hypertrophy and deformity, and to offer no obstruction to the rays. 

Rickets. In this disease the bone appears shorter than normal, the 
diaphysis slender, the epiphyses enlarged, and the line of calcification 
presents an irregular appearance. The delay in the process of ossification 
can be accurately determined. 

Cretinism. In this affection there is supposed to be a premature 
union of the epiphysis and the diaphysis, resulting in an arrested growth 
of the bone. 

Langhans and von Wyss 1 found that there is no hint of premature os- 
sification in cretins and cretinoids, but a late development of the centres of 
ossification occurs, and consequently at or after the age of development, 
the epiphyses show a delayed union ; this delay in the process of ossifica- 
tion, as compared with the normal individual, is of a few years only. The 
bones of the hand are the last to ossify. Hoffnieister, in treating a cretin, 
observed skiagraphically that when the child was treated with thyroid 
extract, the bones under examination grew 4 cm. in four months, equiv- 
alent to 12 cm. in a year, in comparison with the normal growth of 
6 cm. annually. 

Osteomalacia. In osteomalacia the shadows of the bones will be 
transparent, and as the disease progresses there will be a complete ab- 
sence of these shadows. 

Necrosis and caries are characterized by transparent shadows, and irreg- 
ularity in the contour and texture of the bone. (Fig. 155.) Far advanced 
cases will not cast a shadow. Skiagraphy of the sequestra is of marked 
service to the surgeon, informing him of their location, number, and re- 
lations to the bone itself and whether they are still adherent or exfoliated. 
Avoid the superimposition of their shadows with those of the bones. 

B. TUMORS OF BONES. 

Skiagraphy enables us to determine if a neoplasm is connected with 
the compact or cancellous portion of the bone, or if it is connected with 
the bone at all. Thus, the growth might be a cyst or a myoma that 
closely simulates an osteoma, an osteo-sarcoma, etc. 

1 Fortschritte a. d. Geb. d. Runtgenstr., B. iii., 1899-1900. 




PIG. 151. Chronic osteitis with eburnation, as indicated by the arrows. (Case of Dr. M. P. Dickeson.) 




FIG. 152. OSTEITIS OF THE INDEX FINGER. F.B., foreign body which produced the condition ; 
A -< was the point of entrance of the foreign body. (Case of Dr. Prendergast. ) 




Jt 



FIG. 153. TUBERCULOUS OSTEITIS. The dotted area on the fourth metacarpal bone shows tuber- 
culous invasion of the bone. 




FIG. 154. Syphilitic osteitis of the radius. 





FIG. 155. NECROSIS OF THE Os CALCIS. Right-hand picture shows part of the foot of a patient 
who complained of intense pain in the heel, supposedly due to an ill-fitting shoe ; but the X-rays 
revealed a necrosis of the os calcis, with partial absorption, indicated by 1. The left-hand picture 

shows the normal heel. 4 ^-, centre of ossification of the epiphysis of the tuberosity of the cal- 

caneum ; A, astragalus ; 3 O.C., os calcis; 5, fat (dark on the negative) ; C, tendo Achillis ; 7, muscles ; 
8, sinus of the tarsus ; P, plantar arch ; C, cuboid ; S, scaphoid ; V, fifth metatarsal. (Patient under 
care of Prof. H. A. Wilson, service of Philadelphia Hospital.) 




FIG. 156. Supernumerary thumb. ( Case of Dr. George II. Boyd. ) 




; 




FFG. 157. Congenital absence of the ulna and two fingers. (Case of Dr. W. Frank Haehnlen.) 





FIG. 158. Congenital multiple exostoses. (Case of Dr. J. P. Mann.) 



THE CLINICAL APPLICATIONS. 269 

Osteo-sarcoma, like all osseous growths, may be of the periosteal or 
medullary variety. 

In periosteal sarcoma, the growth may be observed to start laterally, 
but later to completely encircle the bone. 

In the early stage the medullary form may be easily confused with 
syphilitic osteitis ; in the latter the tendency is to be formation of clear 
spots, that later become multiple, while osteo-sarcoma begins with a 
single clear spot, becoming gradually enlarged ; it is never multiple. 

Metastatic carcinoma has been shown by Benedict 1 to affect osseous as 
well as the softer tissues. A patient under his care suffered from cancer 
of the kidney, and later had it removed. Four years subsequently, 
intense pain was diagnosed as sciatica, but the X-rays revealed a rneta- 
static carcinoma of the last lumbar vertebra, which was later confirmed 
at post-mortem. Bone cysts can also be detected. 

C. DEFORMITIES OF BONES. 

Among the more common deformities of congenital origin are super- 
numerary fingers, or the absence of one or all of the digits. (Figs. 156, 
157.) There is usually either a second little finger (the most frequent) 
or a second but smaller thumb. We determine if the additional digit is 
simply tagged on by the skin, or if a distinct and completely developed 
articulation exists. In cases of supposed giant finger, the X-rays will 
indicate whether the bone or the surrounding tissue has undergone 
hypertrophy. In cases of syndactylisrn the skiagrapher can often deter- 
mine whether bone itself partakes in the union. Hammer-fingers are of 
interest in that the joint itself is not diseased, there being only a con- 
traction of the ligaments and tendons, as may be demonstrated by the 
fluorescent screen. 

Exostoses show the normal compact and cancellous structures. (Fig. 
158.) There is an overgrowth of the normal bone, the epiphyseal line 
presents a darker color, and from its margins spring peculiar, hook-like 
osseous projections. 

These changes produce an alteration in the curvature of the bone, 
with atrophy of the epiphysis and arrest of the development of the dia- 
physis. Frequently a union of the bones (synostosis) occurs, but the 
growth is usually partially inhibited in one of them, resulting in a pecu- 
liar twisting, readily diagnosed and differentiated from rhachitis and 
other bone diseases. 

Deformities of the pelvis and pelvimetry will be treated of in the 
article on Obstetrics. 

Two interesting cases, studied by Dr. Charles W. Burr, 2 of congenital 
deformities were presumably due to intra- uterine disease of the spinal 

1 Wiener klin. Wochenschrift, June, 1899. 

* Journal of the American Medical Association, June 11, 1904. 



270 ELECTEO-THEEAPEUTICS. 

cord. (Fig. 159.) The first case was a male, fifty-five years of age, four 
feet tall ; head and skin normal, no anaesthesia, sensation preserved all 
over the body ; the reflexes were present. The legs and arms were de- 
formed, and locomotion was prevented by weakness of the muscles. The 
epiphyses of the bones were distinctly abnormal, and the skiagraph 
showed marked absence of lime salts in the bones of the hands. The 
other case was that of a man, aged twenty-three years, in whom the 
shoulders, arms, and forearms had never developed, or there was a retro- 
gression of development. The biceps jerk was absent ; there was no 
disease of the bones ; there was very slight wasting in the left leg, only 
detectable by measurement. Several theories had been advanced as to 
the cause of the condition, among others, bilateral brachial palsy from 
birth, malposition in utero, etc. ; but the author was inclined to believe 
that possibly the patient had disease of the anterior horns of the spinal 
cord in utero. 

Diseases and Deformities of the Spinal Column. The more common 
pathological spinal curvatures are scoliosis, kyphosis, and lordosis. 

In scoliosis the patient should assume the dorsal decubitus posi- 
tion. A skiagram of the ky photic patient is difficult, because the 
plate cannot be properly approximated upon the part, necessitating a 
lateral view with the patient on his side. This, however, will not 
afford a very sharp definition of the shadow, as the plate is too distant 
from the part. 

The same difficulty is encountered in lordosis ; consequently in these 
cases the lateral view must likewise be employed. 

Torticollis. When the deeper muscles are diseased, it not infre- 
quently happens that caries of the cervical vertebras coexists. Its pres- 
ence may be verified by a skiagram in both the antero-posterior and 
lateral views. 

Pott's Disease. It is difficult to differentiate the early stages of Pott's 
disease from intercostal neuralgia, renal disease, empyema with subdia- 
phragmatic abscess, etc. ; but the skiagram will show the bodies of the 
vertebrae and the interarticular spaces to possess a denser shadow than 
normal. In advanced cases the disintegrated osseous tissue will present a 
dark, dense, irregular shadow. Place the patient in the dorsal decubitus 
position, have him flex the knees so as to straighten the spine as far as 
possible and thus bring it in closer relation with the plate. The above 
description applies to any region of the spine. Dark shadows in the 
right iliac fossa, often due to the accumulation of gases in the colon, 
must not be mistaken for necrosis of bone. 

Amputation Stumps. The process of healing can be systematically 
followed in cases of amputation stumps, by noting the existence or ab- 
sence of a fine layer of compact bony tissue, covering the medullary canal, 
and thus the presence of a sequestrum, interfering with the healing, can 
likewise be detected. 





FIG. 159. DELAYED OSSIFICATION OF THE EPIPHYSES. Patient 55 years of age. Every bone deformed. 
Unable to walk since childhood and had been in the hospital more than 30 years. No history of syphilis, and 
Dr. Burr of the Philadelphia Hospital believes the deformities to be congenital and due to disease of the spinal 
cord which developed during foetal life. The epiphyseal ends of the femora, tibiae, and fibulae look spongy from 
lack of ossification. Articular surfaces irregular, bones bent and pervious to the rays. The epiphyseal lines 
appeared darker because of excessive ossification. 



THE CLINICAL APPLICATIONS. 271 

Resection of Joints. Before resecting a joint, the rays will determine 
the exact character of the affection, and their application after the wound 
has been dressed will inform the operator if the bones are in the best 
possible position. 

Regeneration of Bone. After removal of a portion of bone, the peri- 
osteum being left intact, the formation of new bone may be carefully 
observed, and the surgeon can often determine if the proper amount of 
osseous-forming structure has been deposited. 

VI. Diseases and Tumors of the Soft Tissues. 

Tumors of the soft tissues, being only slightly opaque to the X-rays, 
are skiagraphed with great difficulty, owing to the surrounding struct- 
ures having very nearly the same density. For this purpose we employ 
a hard tube with a short exposure, avoiding over-exposure and super- 
imposition of the shadow of the bone. This may also be accomplished 
by diluting the developer and producing a soft negative full of details, 
or by an under-developed negative. The detection of the presence of a 
tumor by a skiagraph will be dependent largely upon the location, size, 
and consistency, and the technic employed. 

In the order of the density of shadows cast, tumors may be arranged 
as follows : 

Hsematomata and Abscesses, 
Myomata, 

Enchondromata, 
Lipomata, 

Fibromata, 
Sarcomata, 

Carcinomata. 

H(ematomata. The blood contained in a hsematoma is more opaque to 
the rays than the surrounding tissue ; hence the shadow cast will be 
darker. Hsematomata may be differentiated from abscesses by the fact 
that the former present a greater density, especially when the blood is 
coagulated. 

Abscesses cast dark shadows on the negative, but not to so great a 
degree as do the hsematornata. In the extremities they are easily diag- 
nosed, but in the abdominal cavity or cranium they are differentiated 
from other growths with great difficulty. Thus, during the past year I 
encountered many obstacles in skiagraphing a condition at the Phila- 
delphia Hospital that resembled appendicitis, subphrenic and hepatic 
abscess. The negative revealed a diffused white spot in the position 
of the lower region of the liver. Dr. Joseph Hearn confirmed the 
diagnosis by operation. Dr. George Pfahler has recently reported 
to the Philadelphia County Medical Society the taking of a successful 



272 



ELECTRO-THERAPEUTICS. 



skiagram of a subphrenic abscess. In January, 1905, I diagnosed skia- 
graphically, at the Philadelphia Hospital, a supposed hepatic abscess, 
but at a subsequent operation Dr. Ernest Laplace proved the affection to 
be cancerous. 

Preutz, of Jena, in a study of 234 hepatic abscesses, speaks com- 
mendably of the great value derived from radioscopy. Myomata and 
fibromata are most difficult to skiagraph, especially in the uterus, where 
superimposition of the shadows of the pelvic bones interferes with a 
differentiation of the tumor from the surrounding tissues. Their shadows 
will be easily recognizable when the neoplasm is large, but manual palpa- 
tion will detect this quite as readily as the skiagrapher can assert the 
presence of this condition. It is worthy of mention that skiagraphs can 
frequently detect the presence of myositis ossificans. 

Enchondromatcij being cartilaginous tumors, are difficult to skiagraph 
because of their transparency to the rays. When the phalanges are thus 
affected, the condition is clearly presented on the negative. 

Lipomata are differentiated from solid and cystic tumors by their 
throwing a lighter shadow, because fat is less opaque to the rays than 

the above named neoplasms. 
X-ray diagnosis between a 
chronic abscess and a liporna is 
quite as difficult as is the differ- 
entiation by clinical means. 

Sarcomata and carcinomata 
cannot be differentiated by their 
skiagraphic appearance. They 
both cast equally dense shadows. 
Tumors of the Brain. The 
difficulties encountered in diag- 
nosing skiagraphically cerebral 
neoplasms are due to the super- 
imposition of the shadows of the 
tumor and the bony vault, the 
softened consistency of the path- 
ological condition present, the 
distance of the shadow from the 
plate occasioned by the arching 
contour of the skull, and the 
production of secondary rays 
due to the marked density of 
this particular region. Formerly I employed the photographic plate ; 
more recently I used a board made in two sections that slide upon a base. 
(Fig. 160.) The boards are hollowed out to conform to the curvature of 
the skull, and may be so adjusted as to widen the concave excavation, and 
thus accommodate any size of skull. In this cavity is placed a double 




FIG. 160. AUTHOR'S HEAD REST. F F, flexi- 
ble photographic film, conforming to the shape of 
the skull and employed for locating foreign bodies, 
etc., in the brain. A lead wire is run from the gla- 
bella to the inion and also over the position of the 
fissure of Rolando. 



THE CLINICAL APPLICATIONS. 273 

coated gelatine film, and the patient' s head is accurately accommodated 
to the shape of the cavity. This also insures steadiness of the part, so 
very important in this difficult procedure. Localization can be mapped 
out by placing metallic wires over anatomical landmarks. 

The use of a compression diaphragm, for preventing the production 
of secondary rays, is largely in vogue in Germany, and has lately become 
popular in America, but this is undesirable, as the area skiagraphed is 
too small to allow of definite and logical conclusions. 

The diagnostic value of the X-rays in neoplasms, abscesses, clots, 
etc., is less than in instances of the presence of foreign bodies. Extended 
literature on the subject is yet to be written. 

Dr. Pfahler 1 gives an interesting account of a case of brain softening 
occurring in the service of Dr. Charles W. Burr. " This case," he says, 
"was one of thrombosis of the mid-cerebral artery, with cystic degenera- 
tion, and causing aphasia and hemiplegia. The examination was made 
post mortem. The brain was replaced and the skull and scalp closed. I 
then made a negative of the affected side and also of the opposite side, 
because I believed that possibly the normal side could be compared with 
the affected side. This case, however, demonstrated that this cannot be 
relied upon, for the lesion was shown upon both negatives, but with much 
more definite outline on the affected side. The skiagraph showed, above 
the cerebellum and petrous portion of the temporal bone, a light area 
which corresponded exactly with the outline of the area of degeneration. 
This skiagraph showed, also remarkably well, the convolutions of the 
cerebellum. 

"The second case was also one of Dr. Burr's, in which an irreg- 
ular area of degeneration was found in the distribution of the mid- 
cerebral artery and which had caused hemiplegia. The skiagraph 
showed transparent areas which corresponded exactly with the area of 
degeneration." 

Dr. Pfahler 2 believes, that " we should be able to show in the skia- 
graph most large lesions, such as new growths, softening, hemorrhage, 
and abscess, but that we should never take the responsibility of an 
operation purely upon skiagraphic evidence." 

Dr. Church, of Chicago, 3 records a case of cerebellar tumor in which 
the Eontgen rays were used by Mr. W. C. Fuchs. Skiagraphs of the 
tumor were obtained. At the autopsy a highly vascular gliomatous tumor 
was found, the tumor being the seat of several old and recent hemor- 
rhages, and also of a recent clot of considerable size. 

Obici and Ballici * demonstrated the presence of a tumor in a boy 
who died of brain tumor, the experiment being performed post mortem. 

^he American Journal of the Medical Sciences, December, 1904. 

2 Ibid., December, 1904. 

3 Ibid., February, 1899. 

c Ri vista di Patholog., October, 1897, cited by Church. 

18 



274 ELECTRO-THERAPEUTICS. 

They also experimented with tumors of different kinds placed in the 
brains of cadavers, and were in some instances able to obtain localizing 
shadows. 

Oppenheim, 1 in reviewing the subject of brain tumors, remarks that 
his attempts with the X-rays for diagnostic purposes were unsuccessful, 
although he was enabled to determine that a tumor placed within the 
cranium upon the brain was distinctly noticeable. 

Pancoast and McCarty * conclude that the value of the Rontgen rays 
in brain lesions is at present dubious. 

Dr. M. Benedikt, of Vienna, 3 described a number of most interesting 
conditions that were both studied and skiagraphed by Dr. Kienbock. 
From a series of cases related by Dr. Benedikt we cull the following facts 
in his own words : "Kolar, M., engine-driver. On June 6, 1897, while 
leaning out of the engine, he struck his head against a lateral object. 
He lost consciousness, vomited, and was confined to his bed for six days. 
He tried to resume his work, but could not continue. On October 16, of 
the same year, he came for the first time under my observation. He com- 
plained of violent headaches, and his face had the rigid expression of a 
mask. On January 20, 1904, I had two profile diagrams taken with the 
Rontgeu rays by Dr. Kienbock. 

"When we ask what pathological process we must assume in this 
case, the answer is a pachymeningitis, especially haemorrhagica, with all 
its consequences, also of alteration in the osseous parts. The enlarged 
shadow of the osseous circumference is not principally the result of thick- 
ening of the bones, but is produced also by pachymeningeal deposits." 

"Bornstein Marcus met with an accident Dec. 24, 1903, while enter- 
ing a railway car not yet lighted. He fell over a trunk and received a 
contusion on the tibia and on the index finger of the left hand. The 
nature of this accident seemed to point to a light lesion. To my great 
astonishment, at the examination (Jan. 4, 1904) serious symptoms were 
found. Standing with open and closed eyes the patient oscillated for- 
ward and to the left side. The supra- and infra-orbital nerves of the left 
side were sensitive to pressure, and the parietal, frontal, and temporal 
bones sensitive to percussion. In these localities the patient felt pains 
when he walked. The turning of the head excited pains, more toward 
the left than to the right side. The cervical and dorsal vertebrae were 
sensitive to pressure, the sensitiveness involving not only the processus 
spinosi, but also the lateral walls of the vertebrae on the left side. The 
pupil reflex was feeble. 

"The left arm and both legs (especially the left one) were adynaruic. 
The patellar reflex was feeble, and especially on the left side. The left 
ear was more sensitive to the tuning-fork, from the air and from the 

1 Diseases of the Nervous System, 1900. Translated by E. Mayer. 
'University of Pennsylvania Medical Bulletin, March, 1903. 
3 The Archives of Physiological Therapy, February, 1905. 



THE CLINICAL APPLICATIONS. 275 

bones of the head. I was more astonished when Professor Eeuss found 
beginning bilateral papillitis n. optici. The range of vision was much 
diminished concentrically, and in the left eye there existed a complete 
defect of vision in au inferior and superior sector. 

"In this case the diagnosis was justifiable that there were serious 
anatomical intracranial lesions, and, as the case was a recent one, also 
blood effusions. Radiographs confirmed this diagnosis." 

I have successfully skiagraphed a blood clot in the brain, and I can 
do no better than quote the words of the late Dr. F. Savary Pearce, 
whose intense devotion to neurology and whose searching inquiry into 
the pathological manifestations of brain lesions made his word authori- 
tative. In his article u Epiphenomena of Cerebral Hemorrhage,' 71 he 
says, li We would like to mention the possibility of the X-ray being a 
favorable adjunct toward determination of a blood clot within the brain or 
not, as a point in diagnosis between hemorrhage or thrombosis and this 
confusing class of Bright's palsies. In a case coming to autopsy at the 
Medico-Chirurgical Hospital ten days ago. Dr. M. K. Kassabian had 
been fortunate enough to find what he thought was a ' shadow ' of the 
thrombotic area in the left lenticulo-striate area region, and this proved 
to be so at the post-mortem examination. In this case, however, there 
was no complication of nephritis in making the clinical diagnosis." 

During 1904 and 1905, I skiagraphed at the Philadelphia Hospital 
a series of cerebral cases in the services of Drs. W. W. Keen, F. X. 
Dercum, and Charles W. Burr. Realizing the imperfection resulting 
from the lightness of the shadow found in skiagraphing brain tissue, I 
took two skiagrams of suspected conditions and applied to the negatives 
obtained the principles of stereo-skiagraphy. The super-imposition of 
the two views thus derived resulted in a clear-cut picture of the part 
under investigation. 

Recently I skiagraphed a cerebral case at the Philadelphia Hospital. 
The patient's skull was bandaged, thus concealing the presence of any 
abnormality. I was ignorant of his clinical history. When the plate 
was developed, I noticed in the motor region, a light area, the size of a 
goose's egg. I then went to the ward to inquire as to the patient's symp- 
toms. I found that this special area was the one complained of; the 
result of a trauniatism, which manifested itself in a slight paraplegia of 
the opposite side. This was undoubtedly an ecchymosis of the cerebral 
ineninges. A false diagnosis was not probable, as there was no wet dress- 
ing or iodoform employed, no exudation of serum or blood, and likewise 
no pressure on the plate that might simulate such a diseased area. Sub- 
sequent examinations failed to reveal the affected region, although the 
skiagraph was taken under the same circumstances. Ultimately the 
patient got well, showing the ecchymosis (exudate) was absorbed. 

'American Medicine, Aug. 9, 1902. 



276 ELECTEO-THEEAPEUTICS. 

Calcareous Deposits in Glands. The shadow thrown by these deposits 
is in some regions of the body dense enough to be mistaken for calculi. 
If there be an abscess cavity, sinus, or fistula, its depth and extent may 
be sufficiently ascertained by introducing either a probe, a packing of 
iodoform gauze, or a rubber drainage tube, and taking a skiagram while 
the introduced substance is in situ. 

Empyema and pleural effusions will be treated of when discussing 
diseases of the thoracic organs. 

Enlarged mediastinal glands, calcified glands, and bronchial glands 
are often visible. 

VII. The Articular System. 

In the normal joint, the cartilage being transparent to the rays, the 
negative will show the inter-articular space black, but it will appear 
white on the skiagraph. The articular extremities of the bones will look 
smooth. In adjusting the tube, part, and plate, care must be taken to 
see that the rays fall directly upon the joint ; for if this precaution 
be not taken, there will result an overlapping of the shadows of the 
articular extremities, the latter leading to a confusion, and causing a 
possible error between a diagnosis of the true condition, aukylosis, and 
subluxation. 

As muscles, tendons, and ligaments are slightly less opaque to the 
rays than are the bones, the tearing off of any of these, as in some sprains, 
can sometimes be shown on the skiagram, provided that the shadow falls 
particularly on the muscular field, and that the negative is full of details, 
the result of good technic. 

A. DISEASES OF THE JOINTS. 

Acute Arthritis. In this affection the skiagram reveals nothing in the 
early stage, save a slight cloudiness or haziness at the inter-articular 
space, due to congestion. Later this haziness increases, and if pus be 
present, the shadow cast on the negative will be darker, as this is less 
opaque to the passage of the rays than is serum. If the arthritis con- 
tinue for a few months, the inflammation will extend to the articu- 
lar ends of the bone, and they will be more opaque to the rays, and 
consequently appear white on the negative. 

Acute and Chronic Articular Rheumatism. The acute stage is identical 
with the description given under acute arthritis. When this condition 
assumes the chronic form, the skiagram will show destruction of the ar- 
ticular ends of the bones, causing displacements of the opposed bony 
surfaces and the attendant deformities. 

Gout. In this disease the tophi (which are composed of sodium 
urate) are transparent to the rays. Yet peri-articular shadows of the 
tophi are often visible in the digits. 



THE CLINICAL APPLICATIONS. 277 

Tuberculous Arthritis. (Fig. 161.) The early stages of tuberculous 
arthritis are most difficult to distinguish from other arthritic conditions. 
But as soon as the bone becomes involved the shadow on the negative will 
be identical with the appearance of tuberculosis of bone previously de- 
scribed ; but with abscess formation, the dark spots on the skiagram will 
reveal the true nature of the malady. When destruction of the soft parts 
of the joint occurs with subsequent absorption of the head of the bone, 
sequestra are formed, resulting in great distortion. 

Coxalgia. In the incipient stage any haziness in the interarticular 
space, in comparison with the unaffected side, is indicative of changes 
in the synovial membrane of the joint, this is likewise true of the 
epiphyseal line. 

Lovett and Brown, in a most elaborate research, 1 arrived at these 
conclusions: "The earliest changes observed radiograph ically in hip 
disease are, first, diminution in the density of the shadow, and second, a 
relative diminution in the size of the shadow cast by the affected bone ; 
in other words, atrophy of the bony substance. 

"The best radiographic evidence is considered to be bony thickening, 
indicated by a shadow projecting inward from the pelvic side of the 
acetabulum ; the head and neck of the femur also may show this 
evidence. 

"Decreased radiability, observed as an indefinite, cloudy appearance, 
which involves not only the bony medulla, but the cortex and periosseous 
structures as well, is frequently seen. This cloudiness was found to be 
due to the presence of thick serum, pus, or finely divided detritus, and is 
apt to be misleading if depended upon to the exclusion of other indica- 
tions. It was sometimes observed where the inflammatory process was 
extra- articular, as in abscess of the groin. 

"Erosion of the bone substance, when present, is usually clearly 
evident on the plate, but is not of itself "conclusive evidence that hip- 
joint disease is present." 

Loose bodies, such as displaced or detached cartilage, are difficult of 
detection because of their transparency. If their shadows are superim- 
posed with those of the bones, recognition is of course impossible, as on 
the shadow of muscles, their detection, at times, is possible. Small sesa- 
moid bones, which may simulate foreign bodies, can also be skiagraphed 
in or around a joint. 

Coxa Vara. "The neck of the femur varies in length and obliquity 
at various periods of life and under different circumstances. In infancy 
the angle is widest and becomes lessened during growth, so that at pu- 
berty it forms a gentle curve from the axis of the shaft. In the adult it 
forms an angle of about 130 with the shaft, but varies in inverse propor- 
tion to the development of the pelvis and stature. In consequence of the 

1 New York Medical Journal, January 28, 1905. 



278 ELECTRO-THERAPEUTICS. 

prominence of the hips and widening of the pelvis in the female, the neck 
of the thigh bone forms more nearly a right angle with the shaft than it 
does in man." (Gray.) 

Skiagraphy in cases of coxa vara reveals the true clinical condition. 
(Fig. 162.) It is found that the axis of the neck to the shaft has materi- 
ally changed its angle, that the affection is non-tuberculous, and that the 
trochanter has changed from its normal position to a higher plane. In 
skiagraphing this condition, inversion and eversion of the feet must be 
vigorously guarded against. This is best accomplished by securely bind- 
ing both feet in the position of a right angle to the leg. A plate large 
enough to include both hips must be employed ; the patient must lie ab- 
solutely flat on his back, with the tube placed over the pubic symphysis 
in the median line. Some operators prefer the ventral to the dorsal de- 
cubitus position. Of course, the position assumed will slightly vary the 
length of the neck of the bone. Consequently the necessity of compari- 
son between the affected and the normal sides. 

Genu valgum is the result of overgrowth of the inner condyle and an 
incurvation of the femoral shaft. The X-rays will show the amount and 
the angle of deformity, and also any alterations in the relaxation and 
elongation of the ligaments of the knee-joint. 

Genu varum is the opposite of genu valgum, and in these cases the 
X-rays will also furnish the operator with complete clinical data. 

Deformities of the foot, including talipes in its various forms, dis- 
placements of the toes, and deformities of the hands and digits can be most 
advantageously studied by corroborating the facts of clinical experience 
with the X-rays. 

B. AETHROPATHIES. 

In the early stages, arthropathies, as manifested in tabes (Fig. 163), 
present a haziness in the joint, identical with the appearance evidenced 
in other forms of arthritis. Later the interarticular space becomes more 
hazy, the periarticular structures are destroyed, the ends of the bones 
irregular and nodular, with rarefaction of the osseous tissue and possibly 
complete disappearance of the bone. In some instances, in place of rare- 
faction, we find thickening or eburnation, with the projection of bony 
excrescences. 

Syringomyelia. Several authorities 1 state, that in syringomyelia there 
is progressive destruction of the joints, greater in extent than is noticed 
in tabes, but marked by an absence of bony excrescences. Mor van's 
disease, often associated with syringomyelia and characterized by the 
formation of painless felons, shows skiagraphically an irregular appear- 
ance and a thickening of the bone, frequently with the presence of 
sequestra. Pulmonary tuberculosis and general systemic diseases may 

'Bouchard, " Trait6 de Radiologie Medicale," 1904. 






FIG. 161. TUBERCULOUS ARTHRITIS OF THE KKEE-JOINT. The left-hand picture shows tubercu- 
lous arthritis of the knee-joint ; 45 indicates the distended capsular ligament ; 3, a narrowing of 
the inter-articular space ; 1 and 2 show the changed character of the epiphyses. The skiagraph was 
taken after the limb had been braced for two months. Right-hand picture shows the normal limb. 
(Case of Dr. J. K. Young.) 




FIG. 162. COXA VAEA. As a result of tuberculosis of the knee-joint. C, cast around the 
right knee-joint. (Case of Dr. James K. Young.) 








FIG. 163. Arthropathies of the knee-joint, in a patient with tabes dorsalis. 
(Case of Dr. Chas. K. Mills.) 




FIG. 164. Penny in the oesophagus. 



THE CLINICAL APPLICATIONS. 279 

also show arthropathies, but will not show the destruction of the articular 
ends of the bones, but there will be revealed a periarticular, semi-opaque 
condition. 

VIII. Foreign Bodies and their Localization. 

In nothing have the X-rays proved themselves of mors incalculable 
service than in the detection and localization of foreign bodies. Prior 
to the discovery of this priceless diagnostic agent, the surgeon found 
himself helpless in cutting down upon a supposed embedded substance, 
but with determination born of forlorn hope, too often he pursued an 
erroneous course, only to find that disappointment and at times serious 
infections were the rewards of his endeavors. 

By the rays the skiagrapher learns not only the position of a foreign 
body, its variety, size, and shape, but also the extent of damage incurred. 

A. MILITARY SURGERY. 

The X-rays have been especially useful in military surgery. Dr. 
Haughton has said, "that the X-rays have furnished the army surgeon 
with a probe which is painless, which is exact, and, most important of 
all, which is aseptic." 

In 1897 the X-rays were for the first time successfully used in the 
Grseco-Turkish war. It was there demonstrated that they were an invalu- 
able adjunct in military surgery, and since that time improvements have 
been made in the apparatus for trials in future field encounters. 

The X-rays were also employed with marked success by Surgeon- 
Major Beevor on the Indian frontier, during the Chitral Campaign in 1898. 

Of no less importance were the experiences of Major Battersby, who 
had charge of the Eontgen apparatus, while campaigning in the Soudan 
a number of years ago. Following the battle at Omdurman, 121 wounded 
British soldiers were brought to Abadith, 21 of whom could not have had 
their condition correctly diagnosed without X-ray examination. 

In the words of Captain W. C. Borden, assistant surgeon in the 
United States Army : l " The use of the Eontgen rays has marked a 
distinct advance in military surgery. It has favored conservatism and 
promoted the aseptic healing of bullet wounds made by lodged missiles, 
in that it has done away with the necessity for the exploration of wounds 
by probes or other means, and has thus obviated the dangers of infection 
and additional traumatism in this class of injuries. In gunshot fractures 
it has been of great service from a scientific point of view, by showing 
the character of the bone lesions, the form of fracture, and the amount of 
bone comminution produced by the small calibre and other bullets, 

1 The Use of the Rontgen Rays by the Medical Department of the United States 
Army in the War with Spain. 



280 ELECTRO-THERAPEUTICS. 

conditions which could not have been otherwise determined in the living 
body." 

Nicholas Senn writes that the expectations as to the diagnostic value 
of the X-rays in military surgery were actually realized in the Spanish- 
American War. He states that foreign bodies were located, fractures 
ascertained, and other surgical conditions studied, without subjecting the 
patient to pain or any danger from infection. 

Mr. Clinton Dent, 1 special war correspondent in South Africa, speaks 
interestingly of injuries by Mauser bullets. If the dense part of the long 
bone is hit by a bullet of the Mauser type, there is a drilling, compli- 
cated by fracture. The extent of the injury depends upon the angle at 
which the bullet strikes the bone, upon the velocity of the bullet, and to 
some extent upon the age of the person. Mr. Dent also observes, "that 
a line drawn between the apertures of entrance and exit does not afford a 
reliable clue of the course that the bullet has followed." He also states 
that fractures with a drilling of the tibia and the upper and lower ends 
of the humerus and radius are common. 

Major Matignon, in reference to the Russo-Japanese war, describes 
at length 2 the installation of an X-ray apparatus in the Fifth Division of 
the Japanese army in Manchuria. This apparatus consisted of a Ruhm- 
korff coil, 30 cm. long and 12 cm. in diameter, with a spark-producing 
power of from 15 to 18 cm. The tube was bi-anodic and 20 cm. long. 
The current was supplied by a dynamo, energized by hand-power. Two 
persons were enabled to bring about sufficient velocity to produce the 
desired current by means of gearing. A portable dark room was pro- 
vided, and Major Matignon remarks: "I was able to discern clearly 
the fractures and the presence of foreign bodies in the hand and in the 
arm." He further states that the use of accumulators and their bur- 
densome construction can thus be readily dispensed with. 

B. VARIETIES OF FOREIGN BODIES. 

These may be transparent, translucent, or opaque to the rays. 

The transparent include such substances as splinters of wood, pieces 
of coal, diamonds, paper wads, leather, clothing, etc. 

The translucent include a fragment of porcelain, paste diamonds, 
small fish bones, other small bones, seeds of fruits, small pieces of 
glass, etc. 

The opaque include metallic substances, such as bullets, coins, nails, 
buttons, pins, needles, jack-stones, marbles, and dice ; also surgical dress- 
ings, dusting powders (e. g., bismuth, iodoform), lead- water and lauda- 
num, corrosive sublimate, dermatol, permanganate of potassium, etc., 
hard -rubber tubes, and iodoform gauze. 

1 British Medical Journal, April 21, 1900, p. 969. 

2 Archives d'Electricite" Mdicale, June 25, 1906. 



THE CLINICAL APPLICATIONS. 



281 



The table below shows the relative transparency of equal thicknesses 
of various substances (water = 1) as found by Bottelli and Garbasso. 1 

TABLE OF PERMEABILITY OF RONTGEN RAYS. 



MATERIAL. 


SPECIFIC 
GRAVITY. 


TRANS- 
PARENCY. 


MATERIAL. 


SPECIFIC 
GRAVITY. 


TRANS- 
PARENCY. 


Pine wood 


056 


221 


Iron . . . 


7 87 


101 


Walnut 


0.66 


1.50 


Chalk 


2.7 


0.330 


Paraffin 


0.874 


1.12 


Antimony 


6 7 


126 


Rubber (pure gum) . . 


0.93 


1.10 


Nickel 


8.67 


0.095 


Wax 


0.97 


1.10 


Brass.. 


8 70 


0.093 


Stearine 


0.97 


0.94 


Cadmium 


8 69 


0.090 


Pasteboard 




0.80 


Copper 


8 96 


0084 


Ebonite 


1.14 


080 


Bismuth 


982 


075 


Woollen tissue 




076 


Silver 


10 5 


070 


Celluloid 




0.76 


Lead 


11.38 


0.055 


Whalebone 




0.74 


Palladium 


11.3 


0.053 


Silk 




0.74 


Mercury 


13.50 


0.044 


Cotton 




0.70 


Gold 


19.36 


0.030 


Charcoal (hardwood) 




0.63 


Platinum 


22.07 


0.020 


Starch 




0.63 


Ether 


0.713 


1.37 


Sugar 


1.61 


0.60 


Petroleum 


0.836 


1.28 


Bone 


1.9 


0.56 


Alcohol . 


793 


1.22 


Magnesium 


1.74 


0.50 


Amyl alcohol . 




1.20 


Coke 




048 


Olive oil 


915 


1.12 


Glue 




048 


Benzol 


868 


1 00 


Sulphur 


1.98 


047 


Water 


1 000 


1 00 


Lead plaster 




040 


Muriatic acid 


1 260 


86 


Aluminium 


2.67 


0.38 


Glycerin 


1.240 


0.76 


Talc (soapstone) 


2.6 


0.35 


Carbon disulphide. . . 


1.293 


0.74 


Glass 


2.6 


0.34 


Nitric acid 


1.420 


0.70 


Tin . 


728 


0118 


Chloroform . ... 


1 525 


60 


Zinc 


7.20 


0.116 


Sulphuric acid 


1.841 


0.50 















C. FOREIGN BODIES IN THE DIGESTIVE, RESPIRATORY, AND GENITO- 
URINARY TRACTS. 

(Esophagus. Foreign bodies in this region can be detected by the 
fluoroscope and skiagram, and should be examined in both positions. I 
recently skiagraphed a child with a penny lodged in the cesophagus, as 
shown in Fig. 164. 

Segond 2 reports a case where a tooth-plate had accidentally been 
swallowed and lodged in the oesophagus. It was located by the X-rays at 
the region of the supra-sternal concavity, and extracted by external 
oasophagotomy. A hook -like projection of the plate forced its way into 
the mucous and submucous coats of the organ, requiring repeated 
fluoroscopic examinations before extraction was achieved. 

Mr. Ballance, of St. Thomas Hospital, London, says that by 
means of a fluoroscopic examination, a hat-pin was demonstrated in the 

1 Bolletino della Societa Photografica Italiana, 1897. 

2 Lyon Medicale, August 5, 1898. 



ELECTRO-THERAPEUTICS. 

oesophagus of an infant fifteen months old. It had travelled to the lower 
third of the tract, where it had fastened itself. A gastrotomy was 
performed and the pin removed. 

Dr. Nathan Eaw 1 reports the swallowing of a tooth-plate by a lunatic. 
The foreign body had descended to a level just slightly below the 
inter-clavicular notch. The fluoroscope revealed the exact position, and 
also showed the plate with its longest diameter lying parallel with the 
transverse axis of the oesophagus. 

Stomach. Almost every variety of foreign body is found in the stom- 
ach, but the movement of that organ makes detection difficult. In skia- 
graphing the stomach, the patient should be placed in the ventral 
posture. Previously, he should have been cautioned against ingesting 
food and drink, as the former will increase the density of the shadows 
and the latter, in addition, offers an opacity to the rays. The foreign 
body is invariably found at the pyloric orifice. 

Several years ago, at the clinic of the Medico-Chirurgical Hospital I 
demonstrated, by means of a skiagram, the presence of tacks, nails, and 
blades of pen-knives in the stomach of the " ostrich man." 

W. S. Halsted 2 publishes a radiogram of a juggler's stomach, from 
which he removed 208 foreign bodies, including 20 links of dog-chain, 
8 pieces of china, 7 knife-blades, 54 nails, and 35 wire nails. 

Diamonds and small stones, being transparent to the rays, defy detec- 
tion. Sometimes diamond thieves have swallowed the stones, but the 
latter could not be found either by fluoroscopy or skiagraphy. In many 
of the mints, suspected employes are subjected to X-ray examinations 
to detect the presence of stolen coins in the stomach. 

Intestines. In the intestines foreign bodies, such as coins, pins, nails, 
Murphy buttons, etc., can be seen gradually to traverse the bowel. The 
peristaltic action of the intestines often interferes with this detection. 
The skiagrapher is further hindered in the cases of children, their crying 
and moving presenting an additional obstacle. So long as the foreign 
body is being moved by peristalsis, the surgeon should not attempt to 
operate. It requires three or four days for a foreign body to be dis- 
charged. Skiagraphy is of special value in impaction of the rectum 
by foreign bodies, so commonly found in the hysterical and insane ; it is 
also of utility in detecting foreign bodies in the appendix. 

Larnyx, Trachea, and Bronchi. The foreign bodies lodged here are 
identical with those found in the stomach. The method of examination 
is likewise similar. 

Genito- Urinary Tract. Almost every conceivable variety of foreign 
body is to be found in the urethra and bladder of the male, and in the 
vagina, uterus, and bladder of the female. ^Recently I examined a patient 

1 The Liverpool Medico-Chirurgical Journal, September, 1901, p. 345. 
'Johns Hopkins Hospital Reports, 1900, vol. ix. p. 1054. 



THE CLINICAL APPLICATIONS. 283 

for fractures of the femora, but instead I discovered a forgotten pessary. 
Forgotten pessaries have often been detected by the X-rays, when the 
cause of the suffering baffled the skill of the attending physician. 

Foreign Bodies Entering from Without. These include bullets, needles, 
cinders in the eye, broken ends of instruments, etc. In surgery we have, 
in addition to the retention of instruments in the cavity of the wound, a 
slipping in of a forgotten section of drainage-tube, and the closure of a 
wound without removal of iodoform gauze, etc. 

D. THE X-RAYS IN OPHTHALMOLOGICAL SURGERY. 

Foreign Bodies in the Eye. The use of the X-rays in ophthalmology 
is principally confined to the detection and localization of foreign bodies 
in the eye. Dr. Van Duyse was perhaps the first to perform experiments 
for locating foreign bodies in the eye, and in March, 1896, he communi- 
cated his results to members of the Medical Society of Gand. 

His first work consisted in the introduction of a small bullet into the 
eye of a rabbit, carefully pushing it up posteriorly to the iris. He pro- 
duced an exophthalmos, and by slipping under the exophthalmic globe a 
small sensitive plate, he was able to define a shadow of the contained 
foreign body. By another expriment he proved that metallic bodies in 
the anterior chamber could be very easily demonstrated by placing a 
sensitive film of proper shape and size between the eyelids at the inner 
canthus and allowing the rays to penetrate the globe from the temporal 
side. 

Dr. Leukowitsch 1 detailed his experiments and results on sheep's 
eyes, with the use of two tubes. He contended, however, that better re- 
sults had been obtained by the use of one tube only. In experimenting 
on the human eye, he employed small sensitive plates, semicircular in 
shape, thus permitting the largest possible area being introduced at the 
inner angle of the eye opposite the lacrymal bone. A large part of the 
eyeball can readily be brought within easy range of the rays by simply 
rolling the eyeball. Eotation of the ball caused a point of fixation, 
which was obtained by employing a glass indicator bent into two right 
angles, a short and straight terminal so placed as to point exactly to the 
antero-posterior axis of the cornea's centre. 

Dr. Max J. Stern, at the Philadelphia Poly clinic, 2 proved that a 
foreign body in any part of the eyeball could be shadowed on the plate at 
the side of the head, and radiographed four patients with steel in the eye- 
ball. He determined the approximate positions of the metal in the eye 
from a study of the shadow of the body in relation to the shadows on the 
plate of the orbital bones ; but the variation in the position of the eye- 
ball in the orbit rendered this method liable to considerable error. 

J The Lancet, August 15, 1896. 
2 Trans. Amer. Oph. Soc., 1896. 



284 ELECTRO-THEBAPEUTICS. 

In February, 1897, Drs. Ring and Hansell each reported one case, 
and Dr. de Schweinitz two cases of steel particles in the vitreous located 
by the X-rays. In one of these cases two previous unsuccessful attempts 
had been made to extract the steel, and it was only after the radiographs 
indicated its approximate position that it was extracted by the magnet. 
These cases were probably the first that demonstrated that the bony 
walls of the orbit and the coats of the eye were permeable to the rays. 
By comparison of the shadow of the metal with that of the margin of the 
malar process of the superior maxillary bone, and the knowledge of the 
relation of the Crookes tube to the sensitive plate, the location of the 
foreign body could be easily demonstrated. 

Dahlefeld and Pohrt 1 report that good records were obtained of 
small fragments of wire and small shot that had previously been intro- 
duced into the orbits. Their method of detection consists in placing a 
focus tube on the opposite side of the head (10 to 15 mm. distant from 
the temple) and a sensitive plate against the temple corresponding to the 
affected side. 

Fridenberg 2 and Friedman 3 both made two exposures of the eye 
and orbit at right angles to each other, while Stockl 4 used pieces of 
lead, fastened at various points around the orbital margin, from which to 
measure the situation of the foreign body. Leonard made a number of 
exposures to give a series of triangles to locate the body. 

For the want of space, I shall include only those methods which in 
my experience have been found most useful. 

Dr. Wm. M. Sweet 5 was the first to devise an accurate method of 
localization, employing for this purpose a plate-holding apparatus, fixed 
to the side of the head on the inj ured side, the fixed points of measure- 
ment consisting of two ball-pointed rods, adjusted at a known distance 
from the centre of the cornea. 

In describing the method, Sweet 6 says: "The determination of the 
location of pieces of metal in the eye or in the immediately adjacent 
tissues by means of the Rontgen rays demands that the shadow of the 
foreign body as shown on the radiograph be studied in relation to the 
shadows of at least two opaque objects of known position. The method of 
judging the approximate position of the body in the eye from the rela- 
tion of its shadow on the photographic plate to the shadows cast by the 
bones of the orbit is less accurate than the method by triangulation, even 
when carried out by making two exposures upon the same plate with the 
tube in different positions, or by making several separate exposures." 

1 Deutsche medicinische Wochenschrift, No. 18, 1897. 

2 Medical Record, May 15, 1897. . . 

3 Klin. Monatsblatt, Oct. 1897. 

* Wiener klin. Wochen., No. 7, 1898. 

5 Trans. Amer. Ophth. Society, May, 1897. 

6 Diseases of the Eye, by Hansell and Sweet. 



THE CLINICAL APPLICATIONS. 



285 



The localizing apparatus designed by Sweet consists of two metal 
indicators, one pointing to the centre of the cornea and the other situated 
to the outer canthus at a known distance from the first. Two exposures 
are made in order to give different relations of the shadows of the indi- 
cators and of the body in the eyeball, one with the X-ray tube horizontal 
or nearly so with the plane of the indicators, and the other with the tube 
below this plane. 

" The principle of the method may be understood from the perspec- 
tive drawing (Fig. 165). Bays coming from the light situated at A cast 




FIG. 165. Principles of the method of localization. (Courtesy of Dr. Wm. M. Sweet.) 

shadows of two ball-pointed rods and an object in the eyeball, and give 
the view shown on the surface C. In this instance the tube is in front of 
the vertical plane of the two indicators, and consequently the shadow of 
the centre ball will be thrown back of that of the outer ball. When the 
light is carried below the plane of the two indicators, the shadows of the 
two rods are formed on the surface D, and the shadow of the foreign 
body in the eye assumes a new position. If the distance of one of the 
indicating rods from the centre of the cornea is known, and the distance 



286 



ELECTEO-THEEAPEUTICS. 



between the two indicators is measured, the position of the metal in the 
eye may be determined, since the shadow of the foreign body preserves 
at all times a fixed relation to the shadows of the indicating balls, in 
whatever position the light is placed. 

" Accurate localization requires that the axis of the eyeball shall be 
parallel with the two indicators and with the photographic plate, that 
one of the indicating balls be opposite to the centre of the cornea and at 
a known distance from it, and that both indicators are at a measured 
distance from each other. The plate-holder and indicators have been 
combined into a special apparatus which firmly holds the head of the 
patient, as shown in Fig. 166. The arrangement of the parts of this 




FIG. 166. Indicating apparatus secured to the side of the head. (Courtesy of Dr. Wm. M. Sweet.) 

apparatus is such that the indicators, while freely adjustable, are always 
parallel to each other and to the plate, and the two balls are perpen- 
dicular to the plate and 15 cm. distance between their centres when the 
apparatus is in place. It is necessary that the patient rotate the eyeball 
to bring the ocular axis parallel with the plane of the photographic 
plate, and that the operator adjust the indicators so that the centre ball 
is opposite the centre of the cornea. 

"To determine the position of the foreign body in the eye, two 
circles are drawn, representing the horizontal and vertical sections of the 
normal adult eyeball, and upon these are marked the situations of the 
indicating balls at the time the radiographs are made. 



THE CLINICAL APPLICATIONS. 



287 




FIG. 167. Outline drawing of a radiograph, made 
with a tube slightly above the plane of indicators. A, ball 
opposite the centre of the cornea ; B, ball to the temporal 
side ; S, foreign body. (Two-thirds normal size.) 



" Lines are drawn through the shadow of each of the indicating 
balls on the two radiographs. On the negative made with the tube hori- 
zontal and parallel with the plane of the indicators, a measurement is 
made of the distance the shadow of the metallic body is above or below 
the shadow of each of the in- 
dicators. This distance is 
entered above or below the 
spots representing the two 
indicators on the diagram of 
the vertical section of the eye- 
ball. Thus, in the radiograph 
(Fig. 167) the distance of 
the foreign body (S) below 
each of the indicators (O S 
and N S) is entered below 
the spots A and B, front 
view, Fig. 169. A line drawn 
through the points C and D 
gives the direction of the 
X-rays at the time the 

shadow of the foreign body was cast upon the plate. Similar measure- 
ments of the distance that the shadow of the foreign body is below 
the shadow of each of the indicators are made on the second negative 
(Fig. 168), and these are likewise entered below the points A and B, rep- 
resenting the two balls on the vertical section of the eyeball. These 

measurements are A F and 
BE. A line drawn through 
the points E and F gives 
the direction of the rays 
when the second negative 
was made. Since these two 
lines indicate the plane of 
the shadow of the foreign 
body at each exposure, the 
intersection of the lines 
must be the location of the 
metal in the eye, as meas- 
ured above or below the 
horizontal plane of the 
globe and to the temporal 
or nasal side. To deter- 
mine the distance of the foreign body back of the centre of the cornea, the 
negative made with the tube horizontal is taken, and the distance is 
measured that the shadow of the ball opposite the centre of the cornea 
lies posterior to that of the external ball. This distance is entered directly 




FIG. 168. Outline drawing of radiograph, tube below 
the plane of indicators. A, ball below centre of the cornea ; 
B, external ball ; S, foreign body. (Two-thirds normal size.) 



288 



ELECTKO-THERAPEUTICS. 



above the external ball on the diagram representing the horizontal 
section of the eyeball. A line drawn from K through the centre 
ball gives the direction of the rays at the time the radiograph was 
made. On the same negative is measured the distance that the shadow 
of the foreign body is back of the shadow of each of the indicators, und 
these distances, B J and A H, are entered on the diagram. A line is 
drawn through the points J and H, and since this line represents the 
plane of the shadow of the foreign body, the point at which a perpen- 
dicular drawn from the situation of metal as shown on the vertical sec- 
tion of the eyeball intersects this line indicates the situation of the body 



Size of body by by mm. 



Situation 

mraback of center of cornea. 
miTvbelow horizontal plane. 

mm.ta side of 

vertical plane. 



Horizontal 
section. 




Side view 



Front view 



'Front view. 



Side view 



FIG. 169. Dr. William M. Sweet's chart for plotting location of foreign bodies in the eye. 
(Two-thirds normal size. ) 

back of the centre of the cornea. If the position of the tube from the eye 
has been measured, its distance is indicated on the line drawn from K 
through the centre ball A. A line through J to this point indicates the 
divergence of the rays. This means of determining the position of the 
plane of shadow of the foreign body is more accurate than when the 
measurement is made of the shadow of the body above each of the balls, 
and should be followed, especially if the body is some distance away from 
the anterior segment of the globe or is in the orbit. 

"If the foreign body has passed into the orbit, the rotation of the 
eyeball to insure parallelism of the ocular axis with the plane of the 
plate leads to a slight error in the determination of the position of the 



THE CLINICAL APPLICATIONS. 289 

metal. To eliminate this error necessitates a knowledge of the angle of 
the orbit with the plate or, its equivalent, the amount of deviation of 
the eyeball from the primary position, and the consideration of this 
angle in plotting the diagrammatic circles representing the eyeball. 

"The indicating apparatus is secured to the side of the head corre- 
sponding to the injured eye, and the tube placed about 12 or 15 inches 
(30 or 38 cm.) to the opposite side and slightly forward. The patient is 
in the recumbent posture, to insure steadiness of the head. After the 




FIG. 170. Mackenzie Davidson's localizer. 

indicating rods have been adjusted, the patient fixes an object about 5 to 
10 feet distant, so placed that the visual axis of the injured eye shall be 
parallel to the photographic plate. An exposure of from 10 to 20 
seconds will clearly outline the bones of the orbit, and secure a shadow 
of any body opaque to the rays in the eyeball or in its neighborhood." 

Another method of equal accuracy was introduced by Mackenzie 
Davidson, who published a description of it in the British Medical 
Journal, January 1, 1896. 

Davidson's Method. (Fig. 170.) The theory of this method briefly is 
as follows : 1 " The Crookes tube is placed in a holder, which can slide 
horizontally. A perpendicular is dropped from the point in the anode of 

lr The Archives of the Rontgen Ray, May, 1898. 
19 



?90 ELECTRO-THERAPEUTICS. 

the tube where the X-rays originate on the point where two wires cross 
each other at right angles, and one of the wires must be parallel to the 
horizontal bar along which the tube-holder slides ; so that, when the tube 
is displaced along the bar, a perpendicular dropped from the X-ray point 
in the anode would always fall upon this wire. The wires in reality rep- 
resent two planes at right angles to each other, and the photographic plate 
representing the third plane. Eventually I obtain the three planes 
which are at right angles to each other, and whose relation to the part 
of the patient's body skiagraphed is known. 

"For practical purposes it is convenient to have the wires stretched 
across a flat board or sheet of vulcanite, and this can be placed on a table 
in the correct position below the horizontal bar, and fixed to the table by 
means of drawing pins. The wires being inked so as to mark the skin, a 
photographic plate, enclosed in black paper in the usual way, is placed 
beneath the cross wires. The perpendicular distance from the anode to 
where the wires cross each other is carefully measured and noted. 

" It is now necessary to decide at what distance apart the tube is to be 
displaced in order to take the two skiagrams. It does not matter greatly, 
2J, 5 or more inches (6 to 12 cm. etc.) of displacement may be given. 
Having decided this point, movable clips are so placed as to limit the 
sliding of the tube-holder to the required extent. The tube is then dis- 
placed to one side, and the patient places the part to be photographed on 
the cross wires, being careful not to move, once the skin has come in 
contact with the wires ; because it is of the utmost importance that the 
shadow of the cross- wires on the negative should be in register with the 
ink mark left on the patient's skin. Further it is convenient to put a 
small coin on one corner of the plate, and also mark the patient's skin 
nearest to it. This reveals to the operator the relation of the plate to 
the skin. 

"One exposure is made, and the tube is then displaced. A second 
exposure is given, preferably on the same plate, provided a suitable 
apparatus be used to enable the plates, if a different plate be used, to be 
changed without disturbing the position of the parts at all. 

"Having developed and fixed the negative, it will show a single 
shadow of the cross-wires, but two shadows of the foreign body. In 
order to interpret this correctly, I devised the following apparatus, which 
may be called the 'cross-thread localizer': 

"A sheet of plate glass is fixed horizontally, having two lines 
marked upon its surface, crossing at right angles in the centre. A 
mirror hinged below it allows the light to be reflected from below, so as 
to render details on the negative visible by ordinary light. 

"A scale fastened to a horizontal bar slides up and down on two 
rods which support its ends. The scale has small notches opposite its 
marks. This is so placed that a perpendicular dropped from the O or 
middle point of the scale falls exactly where the lines cross on the glass 



THE CLINICAL APPLICATIONS. 291 

stage. Furthermore, the edge of the scale is parallel to the line running 
right and left on the glass. The negative is now placed upon this glass 
stage, the operator being careful to bring the shadow of the cross- wires 
into register with the cross on the stage, placed with its marked quadrant 
in correct position. The gelatine surface can be protected by a thin 
transparent sheet of celluloid. 

"The scale is now raised or lowered so as to bring the O precisely 
the same distance above the negative as was the anode of the Crookes 
tube when the negative was produced. All that is now necessary is 
to place a fine silk thread through the notch on one side of the O on 
the scale, and another thread through a notch on the other side, at 
exactly the same distance as that which measured the displacement of 
the X-ray tube. 

11 Small weights are attached to the ends of the two threads to keep 
them taut, while the other ends are threaded into fine needles fastened to 
pieces of lead. Thus the needle with the thread can be placed upon any 
point of the negative and remain in position. In short, the negative is 
now relative to the cross-lines, the scale, and the notches from which the 
two threads come, exactly the same as it was to the cross-wires and 
Crookes tube when being produced. 

" A needle with the thread is placed upon any point on one of the 
shadows of the foreign body, and the other needle is placed upon a 
corresponding point in the other shadow, and it will be found that the 
threads cross each other, just touching and no 'more. The point where 
they cross represents the position of the foreign body. A perpendicular 
can be dropped from this point to the negative below, and a mark made 
at the point where it touches the negative. Then with a pair of 
compasses, the distance of this point from the two cross-wires can be 
measured. 

"The height of the plate where the threads cross gives one co- 
ordinate, that is the depth of the foreign body below the skin, which 
rested on the photographic plate. The other two measurements give the 
other two co-ordinates. 

"As the mark of the wires is left on the patient's skin, all that is 
required is to measure the two co-ordinates on the skin that give the 
point below which the foreign body will be found at the depth given by 
the third co-ordinate." 

Grossman's Method of Localizing a Foreign Body in Eye. Karl Gross- 
man, 1 in localizing a foreign body in the eye, utilized the eye itself for 
the purpose of obtaining the necessary parallax of the shadow ; the 
vacuum tube, the head of the patient, and the photographic plate retain 
their relative positions to one another unchanged. He describes this 
method as follows: "Either one or two pairs of skiagrams are taken. 

1 Liverpool Medico-Chlr. Journal, January, 1899, pp. 359-361. 



292 ELECTRO-THERAPEUTICS. 

The first pair is obtained by making the patient look (a) downward, (&) 
upward, in the same plane, the X-rays coming from the other side of the 
face and somewhat in front of it. If the foreign body be in the eyeball, 
the shadow has moved from (a) to (6) as follows : upward if in the 
anterior half-hemisphere, downward if in the posterior half-hemisphere, 
forward if in the inferior half-hemisphere, backward if in the superior 
half- hemisphere ; the axis of these four half-hemispheres being at the 
same time the axis of rotation for the upward movement. 

"If the shadow has not moved, the foreign body might still be in the 
eyeball, viz., at any point on the axis of rotation. In this case the second 
pair of skiagrams would become necessary, the patient this time having 
to look at a point (c) temporalward, (d) nasalward, in the horizontal 
plane. A movement of the shadow from (c) to (d) would mean the 
presence of a foreign body in the eye, viz., in the temporal hemisphere 
if forward ; in the nasal hemisphere if backward. The relative position 
of the tube, head, and plate need only remain the same for the two ex- 
posures of each pair, viz., for (a) and (&) on the one hand, and for (c) 
and (d) on the other, but may be a different one for each." 

Fox's 1 Method of Localization. (Fig. 171.) Briefly this method con- 
sists first of cocainizing the eye and in the introduction, beneath the 
lids, of an appliance called a "conformer." This device consists of 
an elliptical wire of gold, divided by cross-wires of gold (concaved 
on one side so as to slip over and fit the anterior surface of the eyeball) 
running in opposite axes, dividing the eyeball into quadrants, anteriorly. 
The next step in this method consists in skiagraphing the eye in two 
directions, so as to get good imprints on the sensitive plate of both the 
foreign body and the conformer. Thus, we produce a skiagram in the 
anterior diameter, placing a small sensitive plate in front and against the 
eyeball, and the tube in back of the head, with the target pointing in the 
direction of the eyeball. The tube should be distant from the sensitive 
plate 22 to 30 inches (55 to 75 cm.). The time of exposure is from 1 
to 21 minutes, depending, of course, upon the thickness (or rather the 
antero-posterior diameter) of the head examined. With a properly 
exposed plate and a correctly developed negative, there will result a 
picture showing the relation the foreign body bears to the dividers of the 
conformer. A second skiagram is produced by placing the sensitive 
plate against the temple corresponding to the side that is to be examined, 
and the tube on the opposite side, with the target pointing in direct line 
with the temples. The tube should be from 20 to 30 inches (50 to 75 cm.) 
distant from the sensitive plate. The time of exposure should be from 1 
to If minutes, depending upon the thickness of the head in this diameter. 
This skiagram shows the depth of the foreign body, measured from the 
peak or base of the conformer. 

1 Philadelphia Medical Journal, February 1, 1902, pp. 213-220. 




N.B. 



... J 

FIG. 171. Fox's LOCALIZER.- Bullet in the orbit : 5 >-, shot. The wire over the cornea illus- 
trates Fox's method of localization. 1, frontal sinus ; 2, thickness of frontal bone ; 3, the zygoma ; N.B., 
nasa! 'bone. 



THE CLINICAL APPLICATIONS. 



293 



This method is entirely different from any of the others, and, unless 
great care is exercised in securing the exposures at right angles to each 
other, the chance for error in localization is great. Prior to this method 
I placed the conformer over the closed eyelids. 




E. VARIOUS METHODS OF LOCATING FOREIGN BODIES. 

Screen Method. This was the first method employed. In order to 
attain the best results, the examiner should have had thorough experience 
in this line of work. The fluoroscope should first be used, to demonstrate 
the presence of the foreign body. The hood is next removed from the 
screen, and the latter used sep- 
arately, in the same position as 
when first located. A mark, 
made by an indelible pencil, is 
placed on the part directly over 
the spot where the shadow of 
the foreign body presents itself, 
this mark being directly behind 
the screen. 

A second mark is made on 
the opposite side of the member 
corresponding to the area of the 
foreign body. These marks, ly- 
ing in an even plane, should be 
both marked "1" and "1." 
The depth of tissue in which the 
bullet lies is next ascertained by moving the screen slightly up and 
down ; if the shadow of the foreign body moves considerably, it indi- 
cates that the foreign object is deeply imbedded. On the contrary, 
if the shadow moves but slightly, it indicates that the object is superfi- 
cially imbedded. The next step consists in viewing the foreign body at 
exactly right angles to the first position ; to do this the part under exami- 
nation, and not the tube, should be turned. The skin of the part should 
be marked over the area of the shadow at both sides by the figures "2," 
"2." Next in order draw lines from 2-2 and 1-1, and the point of 
intersection corresponds to the exact location of the foreign object. For 
marking the skin, some prefer diluted silver nitrate crayons, but, as 
they are more or less irritating, I employ indelible pencils. Fig. 172 
illustrates a simple method of localization. 

Punctograph. This consists of a stout brass ring securely mounted to 
a handle of ebonite. A pencil of aniline is attached to the base of the 
handle. The pencil is controlled by a check spring, and when the latter 
is pressed, the pencil is released, which now jumps through the centre of 
the brass ring, marking the skin at the point where the shadow presented 



FIG. 172. THE RIGHT-ANGLE METHOD OF LO- 
CALIZATION. P, photographic plate; T 1 , position of 
the tube; T 2 , position of the tube at right angles to 
the above; F.A, foreign body. 



294 ELECTRO-THERAPEUTICS. 

itself, as seen through the screen. In localizing a foreign body by this 
method, two of these instruments are simultaneously employed. The 
screen should be clamped to a frame, thus allowing the hands perfect 
freedom for manipulating the two instruments. 

In examining the forearm for a foreign body, let us say a bullet, the 
part is brought between the screen and the tube, and the shadow revealed. 

The first punctograph is then placed so that the opening of the brass 
ring encircles the shadow cast by the bullet. A second punctograph is 
applied similarly and directly opposite the first. The springs of both 
punctographs are now simultaneously released, and there result marks 
on the skin at opposite ends of a line. The arm is next rotated through 
the quadrant of a circle, the punctographs again being applied, and the 
springs released as in the beginning. It must thus become self-evident 
that four marks are now upon the arm, and by ordinary calculation and 
measurement the position of the bullet may be easily determined. 

Remy's Method. The Remy localizer, which is an extremely compli- 
cated device, and is with greatest difficulty elucidated by the use of dia- 
grams, is thus briefly reviewed by A. "W. Isenthal, F.R.P.S., and II. Snow- 
den Ward, F.R.P.S., members of the Council of the Rontgen Society. 1 

"The Reniy localizer is a complicated apparatus, founded on the 
principle that it is necessary to 'materialize' those two X-rays which 
connect the anode with the foreign body and its screen shadow for two 
positions of the tube. By means of suitably placed sights and stops, one 
is enabled to bring the pointed rods (representing the X-rays) always 
back to their proper plane, so that the latter and the depth of the 
foreign object may be marked on the patient." * 

Barrel's Method. Frank R. Barrel, M.A., B.Sc.,of the University 
College, Bristol, England, thus tersely describes his localizer. 

"My method requires no plumb-line, no threads, and no levelling. 
My 'apparatus' consists of two metal cylinders whose ends have been 
carefully turned perpendicular to their axis. A convenient size is four 
inches long and one inch in diameter. Place these cylinders upright on 
the plate during an exposure, and close to the limb holding the foreign 
body. The shadows thrown indicate the focus position of the tubes. To 
secure good long shadows, place the cylinders near the end of the plate 
furthest from the tube. After the first excitation shift the tube six or 
ten inches, the cylinders are also shifted towards the opposite end of the 
plate, and then the tube is again excited, giving rise to the second set of 
shadows from the foreign bodies and the cylinders. Lines are ruled 
along the edges of the two corresponding cylinder shadows for one tube 
position, and, producing them till they meet, we obtain that point on the 

1 Practical Radiography, Dawbarn and Ward, Publishers, 1901. 
* For a comprehensive description of the apparatus and its mode of application, 
the reader is referred to Archives of the Rontgen Ray, August, 1900. 
* Archives of the Rontgen Ray, May, 1900. 



THE CLINICAL APPLICATIONS. 295 

plate which was vertically beneath the tube focus during the correspond- 
ing exposure. Connecting the two points thus found with the corre- 
sponding shadows of the foreign body, we obtain two lines which intersect 
in a point which is vertically below the actual: foreign body." 

Shenton's Method. 1 For such cases as needles or bullets in the hand, 
arm, or leg, i. e., in parts easily manipulated, no special apparatus is 
required and no photographic process involved. Shenton describes his 
method as follows : "Hold the part, for example, a hand containing a 
needle, before the fluorescent screen. Start with the screen and the 
anode of the tube as nearly parallel as possible. When needle and bones 
are distinctly seen, sway the screen and hand from side to side, and note 
the change in relation of bones and needles. It is evident that the image 
of whichever is furthest from you and from, the surface of the screen 
will move the faster. If the needle moves across the bones, its position is 
deeper than the bone ; if bones move across needle, the latter s position 
must be between the surface of the screen and the bone. Should the 
needle appear to remain stationary, place a pointer against this image on 
the screen, and ascertain whether it moved a little or not at all. Verify 
these results "by reversing the hand and repeating the mano3iivres. A 
little practice enables one to give as near an estimate of the needle's real 
depth as any surgeon could require, and such suggestions as ' j ust beneath 
the palm,' 'midway between bones and skin,' 'lower end between the 
bones,' 'upper one-eighth of an inch between the skin of the back of 
the hand,' are, in my experience, sufficient for any operator. I doubt 
if a calculation in millimetres would be of more use. The body is an 
awkward thing to apply the millimetre scale to, and a little pressure on 
the skin, or a little swelling beneath it, will overthrow such minute 
calculations. The needle's depth being ascertained, it only remains to 
find its position in the horizontal planes, a task which presents few 
difficulties. 

" When found, this position should be marked upon the skin. The 
advantages of this method are its rapidity of performance, the process 
taking but a few seconds, and the economy of material, both photo- 
graphic and electrical. For localization in other parts of the body, and 
for photographically recording results, I have constructed an instrument 
which in principle is the same as the method just described, save that the 
tube is swayed, while the part viewed is held in position by bands and 
tension springs. The tube is moved by the observer from his side of the 
screen, the distance it travels being regulated by sliding steps. A fine 
vertical wire is stretched in the centre of, and in contact with, the screen. 
The image of the foreign body is to correspond with this line when the 
tube is in the mid-position. Upon moving the tube from the extreme 
right to the extreme left, the image of the foreign body on the screen is 

1 Archives of the Ri'mtgen Ray, August, 1899. 



29G ELECTRO-THERAPEUTICS. 

seen to pass from left to right. Its relative rate of travelling, compared 
with the same portion of bone, is noted as before. For accurate measure- 
ments the true position assumed by the foreign body is marked by 
pencil on a celluloid film in contact with the screen. This measurement 
being secured, the distance the tube travels, and the distance from the 
mid-point of the line adjoining the two extreme positions of the tube, 
must be ascertained. A simple rule of three will now give the distance 
of the object sought from the screen." 

Harrison's Method. 1 "A seven-inch square is drawn on a board and 
its centre is accurately marked ; at the ends of a line drawn through the 
centre, perpendicular to two of the sides, two upright rods are fixed (for 
convenience of carriage, these can be made to take in and out) ; at a 
height of seven inches on each of these pillars, a hook or loop is placed. 
Take the case of a needle in the hand. A double photograph of the 
needle and hand is taken with" the light alternately right and left. A 
tracing of this photograph is then taken on the sensitive side, marking 
distinctly on the ends of the needle. The tracing is then placed so that 
its centre coincides with the centre of the square. Pins are then stuck, 
slantingly through the tracing, into the board at the ends of the needle. 
Cross threads are carried from the pins to the loops and kept stretched 
by small weights. Where these threads intersect will show the position 
of the needle relatively to the sensitive plate, which is represented by 
the tracing." 

Double Focus Tube Localization. This method was devised by Leon- 
ard * and is as follows : The technic required for triangulation methods 
prevented their general employment, and to simplify the application of 
the same principles, Leonard has had made a tube with two cathodes and 
two anodes, and hence two sources of rectilinear rays. This avoids errors 
when the position of the tube has to be changed or separate plates used, 
and it has made rapid accurate localization with the fluoroscope easy. 
The fluoroscopic method is as follows : Fix the screen in a perpendicular 
position. Place the tube horizontally so that the mid-point of the line 
connecting the two sources of rays is perpendicular to the plane of the 
screen, and at a known distance from the centre of the screen marked by 
an opaque cross. Place the limb before the screen so that the two shadows 
of the foreign body will fall equally distant on each side of the opaque 
spot and on the same line. Mark the spot in the patient's skin with 
nitrate of silver. By placing an opaque rod on the other side of the limb, 
where its shadows are equidistant from the opaque spot, the perpendicu- 
lar is found and marked on that side. The foreign body, therefore, lies 
on this line at a distance from the opaque spot, that is determined by 
measuring the distance between the two shadows with calipers and 

1 British Medical Journal, April 2, 1898. 
1 American X-ray Jour., November, 1899. 



THE CLINICAL APPLICATIONS. 297 

plotting the shadowy paths by the graphic process, as when plates are 
employed, or by the cross-thread method. 

Stereoscopic Method. This method has already been discussed. I 
employ it, as it has yielded satisfactory results. 

Triangulation Method of Localizing Foreign Bodies with Measurement 
on a Graduated " T" Scale. (Figs. 173, 174.) In order to find the depth 
of the foreign body on the scale, bring the lower bar to the figure 10 on 
the upright. Connect a line at 20 on the uppermost horizontal bar, inter- 
secting at 1.6 [DE] ou the middle horizontal bar, which registers 4. 53 cm. 
on the vertical bar, as shown in the following formula : 

A Position of the tube in the first exposure. 
B = Position of the tube in the second exposure. 
AB = Distance of the displacement. 
C = Foreign body. 

D = Shadow of the foreign body on the plate (first exposure). 
E = Shadow of the foreign body on the plate (second exposure). 
CA == 50 cm. CD. 

There are two triangles, = CAB and CDE. 
DE = 1.6 cm., which is known. 
AB = 20 cm. 

CD = CA 20 CD = 2(50 cm. CD) 
2 "20 20 CD = (100 cm. 2CD) 
20 CD + 2 CD = 100 cm. 
22 CD = 100 cm. 

100 

CD = - = 4.53, distance of the foreign body. 
^2 

Orthodlagraphic Localizer of Grashey. Frequently it is found that 
foreign bodies imbedded in the tissues cannot be located with exactness, 
even when felt beneath the skin, or when Rontgen photographs are taken 
in diiferent projections, because of the possibility of the foreign body 
varying its position to the bony parts from minute to minute. If the 
hand during the operation is not kept in exactly the same position as 
during the taking of the photograph, then the projection will be wrong. 
Eecently Dr. E. Grashey, of Munich, devised an orthodiagraphic 
localizer. (Fig. 175.) 

The operator sits before the table and is looking with one eye into 
the tube, and he sees an illuminated picture in the mirror of the crysto- 
scope. With the other eye (the room not being darkened) he can look 
directly at the wound. The current is interrupted and closed by the help 
of a pedal. The tube is enclosed in a box, containing below a diaphragm, 
capable of effecting so small an opening that only a limited field of opera- 
tion is illuminated. In this way, and by a plate of lead glass inserted in 
the front wall of the box, the operator is protected. The box is fixed on 
a support connected with one leg of the table, and revolves horizontally. 
Thus, it can be turned aside with a sterilized cloth, and when its use is 



298 



ELECTRO-THERAPEUTICS. 



again required it can be turned back, and it will be at once over the 
former position, above the fluoroscope. The forearms of the operator rest 
comfortably on movable supports. 

The illustration (Fig. 176) shows the path of the rays emanating 
from the anode of the tube R, that is in the box BK. Through the open- 
ing B, in the diaphragm, we see the body K, containing the foreign body 







FIG. 173. "T" scale used in triangulation method. FIG. 174. Scheme of application of the "T" scale. 

F. Upon the fluoroscope L, inserted on the table O, this picture is ob- 
liquely reflected by the mirror S, in the dark chamber D, into the tele- 
scopic tube T. In that case the anode focus and the centre of the fluo- 
roscope M, marked by a little shot pasted on it, lie vertically one below 
the other. Thus it becomes easy to adjust any other body orthodiagraph- 
ically in line with the normal ray, as, for instance, the foreign body F 
contained in the hand K. If you move the point of a knife into the 
illuminated picture until its shadow covers that of the shot and also 
the foreign body that has previously been adjusted, then the point of the 
blade must be exactly above that of the foreign body. 



THE CLINICAL APPLICATIONS. 



299 



For the determination of the location of a foreign body, whether 
in the eyeball or orbital cavity, take two separate skiagraphs, with the 




FIG. 175. Orthodiagraphic localizer of Grashey. 




FIG. 176. Diagrammatic view of the same. 

tube-holder and plate in the same position in both instances ; or during 
half the exposure the patient rolls the eyeball ; if the shadow of the 
foreign body appears double, the offending substance is in the eyeball ; if 
in the orbital cavity, the shadow will be single. 



CHAPTER IV 

APPLICATION OF THE X-EAYS IN DISEASES OF THE 
THOEACIC OEGANS. 

THIS is subdivided into the respiratory and circulatory systems. 

The value of the X-ray as a diagnostic agent in thoracic examinations 
has been and is being constantly demonstrated. The thorax and its 
contained viscera are easy of examination both by the fluoroscope and 
skiagram, largely due to the circumstance that the lungs are transparent 
to the rays. By a fluoroscopic examination we observe the excursions of 
the diaphragm, the expansion and retraction of the lungs and ribs, the 
different phases of the cardiac cycle, and the pulsations of the aorta. 

The fluoroscopic interpretation is not the work of the novice. The 
beginner should first study the thoracic viscera fluoroscopically upon thin 
subjects and children, so as to accustom himself to the appearances 
presented normally. 

The two methods of examination are with the fluoroscope and the 
skiagram. The advantages of the fluoroscope are these ; it is inexpen- 
sive, easy of application, the part may be viewed from any direction, 
the intensity of the rays can be altered, the position of the patient, tube, 
and fluoroscope can be changed, movements of the thorax and its con- 
tained viscera can be studied and tracings made of their shape, size, and 
position. The disadvantages are the liabilities to burns, the lack of 
differentiation of the tissues of slightly varying densities, and the fact that 
the image is only transient. 

I. Fluoroscopic Examinations. 

Anterior and Posterior Views. The screen, in an anterior view of the 
chest, shows a dark zone extending from the base of the neck to the 
diaphragm, a little to each side of the median line of the body ; this is 
the shadow cast by the dorsal vertebrae, sternum, and heart. On both 
sides of this dark zone are the much lighter shadows produced by 
the lungs ; traversing the lung shadows, on both sides from the shadow 
cast by the spine, are successive darker bands, the ribs. The heart's 
pulsations, its position, shape, and size can all be viewed by careful screen 
examinations. The ventricular chambers always present a dark shadow, 
the right auricle giving usually a lighter shadow than the left. Above 
the shadow of the ventricles and slightly to the left is the shadow of the 
pulmonary artery. In the first left intercostal space may be seen a part 
of the arch of the aorta. The shadow of the heart's apex will be observed 
to blend with the shadow of the diaphragm. The border of the pulsating 
300 



APPLICATION OF THE X-KAYS. 301 

heart presents a slightly lighter shadow than its interior. The cardiac 
outline is best viewed through the anterior thoracic wall. A posterior 
view of the heart is less distinct, because of the intervening spine and 
lungs and of its anterior position in the chest cavity. 

In a posterior view, a dark shadow corresponding to the left side of 
the heart is seen to the left of the spine, and a smaller and slightly less 
distinct but denser shadow of the right auricle is seen to the right of that 
produced by the spine. The organs of the thorax, represented on the 
screen, may be easily recorded in the following manner : The operator 
should employ a screen of sufficiently large dimensions to cover the entire 
chest, and upon whose dorsal aspect has been placed a sheet of white linen 
writing paper. In order to maintain a constantly steady position of the 
screen for a uniform and correct tracing, the patient should be seated 
comfortably, so that he may not move. The screen should be supported 
by a movable frame fastened to the arm, coming from a metallic upright 
free from all undue vibrations, as otherwise the examination will prove 
unsatisfactory. The screen having been placed either in front or in back 
of the patient's thorax (leaving 1 inch (2.5 cm.) space between the screen 
and chest), we are ready to trace on the paper the image cast on the 
screen by the use of an opaque pencil, preferably one that is indelible. I 
believe, however, that the orthodiagraph is always more desirable. 

Lateral and Oblique Views. In the lateral view, especially when seen 
from the patient's left side, the operator observes the heart in contact 
with the anterior chest wall, also the profile view of the heart, the aorta 
arching backward to approach the vertebral column, and an unobstructed 
interval between the posterior part of the heart and the spine. 

The oblique view, which can be antero-lateral or postero-lateral, right 
or left, is taken with the fluoroscope at an angle of about 45 to the 
vertical axis of the body. This view is of value in an obscure diagnosis, 
in furnishing additional and often confirmatory data. 

Examination of the Lungs. The image of a normal lung, on a fluores- 
cent screen or fluoroscope, is bright, the rays penetrating with less resist- 
ance the spongy tissue than ordinary dense tissue. This brightness of 
the screen differs in degree during the various stages of respiration. 
When the lungs are inflated to their fullest extent, there is represented 
on the screen a uniform bright light shadow. At the end of the fullest 
expiration the above degree of brightness has considerably diminished, 
as the lung tissue has become more compact. Between these two extremes 
there is a medium degree of brightness, obtained when respiration has 
temporarily been halted midway between inspiration and expiration. 

As we would also naturally expect, in children and in thin adults the 
lungs appear brighter on the screen than in muscular or corpulent indi- 
viduals. In the latter class of cases, as more tissue must necessarily be 
traversed by the rays, there is more chance for their absorption, hence 
the giving of more " shadow." 



302 ELECTEO-THEKAPEUTICS. 

In examining a lung from below upward, the brightness of the 
shadow very slightly increases as we approach the apex. Usually the 
right lung presents a slightly lessened degree of shadow brightness as 
compared with the left. The shadow of the right apex in normal cases 
is always darker than the left. No satisfactory explanation has ever 
been given concerning this difference. Some authorities maintain that 
it is due to a slight hypertrophy of the muscle tissue of the right side 
of the chest. It is more marked in right-handed people, and we might 
naturally infer that the opposite would be true in left-handed people, 
although observations on such subjects have also proved the contrary to 
be the case. 

Normal Heart and Diaphragm. Dr. F. H. Williams 1 states that the 
radioscopic appearances of the normal heart and diaphragm as seen by 
a screen examination in the anterior view are the following : 

"In health the diaphragm moves as follows : Quiet breathing, one- 
half inch (1.3 cm.) ; at full inspiration 2J to 3 inches (6.5-7.5 cm.), and 
slightly more on the right than on the left side. A part of the aorta in 
some patients may be observed in the first intercostal space ; in the sec- 
ond intercostal space a portion of the pulmonary artery ; the left border of 
the ventricle is chiefly seen during a full inspiration, when the apex and 
a portion of the lower border are also visible ; the maximum pulsation 
is at a point corresponding to the cavity of the ventricle, about where its 
outline crosses the fourth rib ; during full inspiration the heart moves 
downward to the sternum. To the right of the sternum the outline of 
the large vessels is seen and, less distinctly, the right auricle between the 
second and fourth ribs. The right auriculo- ventricular line curves, with 
a slight indentation, from the second to the sixth ribs inclusive. During 
the momentary elevation of the diaphragm this line is pushed upward 
and outward. During a forced depression of the diaphragm it elongates 
and is carried downward and inward toward the sternum. Under ordi- 
nary conditions we find the lowermost portion of the heart's shadow fus- 
ing with that of the liver and the diaphragm." 

Dr. Albert Abrams* says : "The average normal excursion of the 
diaphragm in quiet breathing is five-eighths of an inch or 1 j cm. ; between 
full inspiration and expiration, on the right side, 2| inches or (about) 6.7 
cm. ; left side, 2f inches or 7 cm. 

' ' In long-chested persons diaphragmatic excursions are greater than 
in short persons with deep chests." 

Measurement of the Diaphragmatic Incursion. Dr. H. Gruilleminot 3 
says : "On account of the slope of the diaphragm backward and down- 
ward, the highest point of the diaphragmatic arch is nearer the anterior 
than the posterior surface of the body. Moreover, the point of contact 

1 The Rontgen Rays in Medicine and Surgery. 

1 Journal of the American Medical Association, May 3, 1902. 

8 Archives of the Rontgen Ray, January, 1906. 



APPLICATION OF THE X-KAYS. 303 

of the tangent ray is displaced with the movement of the diaphragm, 
and this displacement varies with the subject and with the distance of 
the anti-cathode. All these cases of error are avoided by the use of 
orthodiascopy. " He, in collaboration with M. Yanuier, obtained a 
tabulation of 23 cases, comprising normal lungs and tuberculous lungs in 
every stage. From their observations they arrived at the following 
conclusions : 

1. " On the right side the mean position of the diaphragmatic curve 
is 16.5 cm. below the suprasternal line, and on the left side it is 18.5 
cm. below that line. 

2. " The normal amplitude of the diaphragmatic incursion is from 
16 to 18 mm. It is approximately equal on the two sides. 

3. " Any variation in the amount of the incursion on the right and 
left sides is a pathological symptom, and in most cases has a serious 
clinical significance. 

" The ratio between the amplitude of the diaphragmatic incursion 
and the costal angle depends greatly on the type of respiration, whether 
costal or abnormal. 

"The inequality of the incursion of the diaphragm on the right and 
left sides is an important aid to diagnosis." 

TJie Measurement of the Costal Angle. Guilleminot has shown the 
possibility of radiographing the thorax in inspiration or in expiration. 
This may be accomplished by dissociating the phases of inspiration and 
of expiration by means of an automatic interrupter. 1 By this means 
one can obtain a cinemato-radiograph of the respiration. On these 
radiographs one may measure the obliquity of the ribs between two 
points on the upper margin of the rib at a distance of If and 2i inches 
(4 and 8 cm.), respectively, from the median line. If we now take any 
horizontal line and measure the vertical distances of these two points, 
the difference of the two ordinates will give us the obliquity of the 
rib for a distance of 4 cm., and this divided by 4 will give us the 
obliquity per centimetre. This is the cotangent of the angle with the 
vertical, made by a line passing through the given points. 

" By this means it is easy to determine the costal angles of inspira- 
tion and of expiration. Their difference is the functional costal angle, 
which may vary from 3 to 5. 

"The orthodiascopic procedure is much more simple. 

""With practice one is able to distinguish the projection of the up- 
per border of a rib at its position of maximum elevation and depression 
while the patient breathes rather deeply. 

"In each case it is important to note accurately the physiological 
type of the respiration, which may vary in all possible degrees between 
the abdominal and the superior costal type. For this purpose the 

1 Comptes-rend. Acad. Science, June 12, 1899. 



304 ELECTRO-THERAPEUTICS. 

tracing of the costal range should be accompanied by a tracing of the 
diaphragmatic incursion. 

"If we take the means of these measurements, we obtain the 
following results : 

( Inspiration, 77 J \ 

Left < > Mean position, 74 J 

(.Expiration, 72|J 

f Inspiration, 76 J ) 

Right \ I Mean position, 74| 

( Expiration, 73 J 

"In these observations the mean angle is the angle which the 
rib makes with the vertical when it is in a position midway between 
inspiration and expiration. 

"The absolute coincidence of the mean angles on the right and left 
sides is certainly accidental, there being considerable divergence in cer- 
tain instances. 

"The mean costal angle may therefore be said to be approximately 
equal on the two sides, and to be about 74 to 75. 

( Left, 78.6 ) 

Inspiration \ } Mean, 78.2 ^> 

( Right, 77.8 J 

}- Difference = 5.4 



f Left, 72.7 ) 

Expiration 4 [ Mean, 72.8 J 

I Right, 72.9 J 



"The functional costal angle, therefore, in healthy subjects is equal 
on the right and left sides, and usually varies between 5 and 6." 

Causes of tlie Restriction of the Diaphragmatic Wave. Albert Abrams l 
says, in this connection: "The restricted diaphragmatic movements 
must be regarded as very suspicious of phthisis. This sign, first referred 
to by Williams, of Boston, has had no theory advanced to explain its 
existence. I will briefly summarize my investigations which gave birth 
to the theory that an emphysematous condition of the lungs exists in 
phthisis. Rokitansky and Brehmer noted that lungs too voluminous 
coupled with a small heart characterized the phthisical habitus. If the 
physician were to depend on percussion dulness as an evidence of early 
phthisis, the affection would never be recognized ; lung resonance, not 
dulness, is the early physical sign of phthisis. The rays are invaluable 
in the recognition of emphysema ; in this condition, the lungs seem too 
large for the chest, the diaphragm is low and its excursions restricted." 

Diseases of the Diaphragm. "In spasm," says Abrams, "dia- 
phragmatic movements are practically suspended on the affected side. 

'Journal of the American Medical Association, May 3, 1902. 




(dorsal decubitus). Patient lies on a 14 in. x 17 in. (35 x 42 cm.) plate, with the 
head ; the anode at a distance of 25 in. (62 cm.) in the median line, correspond- 



FIG. 176A. Luxos 
arms extended over the hea 

ing to the junction of the third and fourth front ribs. This position may be employed in radiographing 
the arch and descending aorta. For radiographing the heart, the tube must be displaced downward 
to the fifth interspace. 



APPLICATION OF THE X-EAYS. 305 

Suddenly the diaphragm contracts and descends several inches below its 
normal descent. Singultus may accompany the descent, whilst cyanosis 
and dyspnoea become intense. In paralysis, movements of diaphragm 
on the affected side are suspended ; during inspiration, the midriff rises. 
In diaphragmatic pleurisy, movements of the diaphragm are very much 
restricted or even suspended. The upper part of the lung is brighter 
than normal, owing to over-distention. 

11 Average Normal Excursion of the Diaphragm. In quiet breathing, 
lj centimeters ; between full inspiration and expiration, 6.7 cm. on the 
right side and about 7 cm. on the left side. In long-chested persons 
the diaphragmatic excursions are greater than in short persons with 
deep chest. 

" Width of the Normal Heart. "With the screen about 75 cm. from 
the tube and with the target directed toward a point where the median 
line is crossed by the fourth rib, the right heart measures 3 cm. from the 
median line, and the left heart 8.5 cm. from the median line ; a total 
of 11.5 cm." 

II. Skiagraphic Examinations. 

The lungs may be examined in two ways, fluoroscopically and skia- 
graphically. What is stated below regarding the methods of examination 
is equally true for both the normal and abnormal lung. 

Position of the Patient. Skiagrams of the lungs may be made with the 
patient either in the sitting, semi -recumbent, or dorsal decubitus posture. 
In my experience the latter has always proved to be the more satisfactory 
of the two. The patient is requested to remove all clothing covering the 
thorax, in some cases not even permitting the retention of a garment 
next to the skin. 

When the dorsal decubitus position cannot be taken, the patient 
starting to cough, or if he is suffering from dyspnoaa, he should be re- 
quested to resume the semi-recumbent posture, having the head-end of 
the table elevated to an angle of 45, so as to insure greater comfort and 
also in a measure to remove the pressure exerted upon the diaphragm 
and the adjacent lungs. I always request the patient to elevate the arms 
and clasp the hands over the head, in order to raise the scapulae and 
thus remove their shadows from the shadow of the thorax. 

Place two superimposed sensitive plates, well protected by a thin 
layer of celluloid, under the patient's thorax. The size of the plates 
employed will depend upon the size of the patient's chest; the plate 
should be slightly larger than the chest itself so as to extend on both 
sides about two inches beyond its outer margins. 

The tube should be placed with the target pointing directly toward 
the centre of the whole thorax and from 20 to 25 inches (50 to 63 cm.) 
distant from the plate, depending upon the thickness of the chest and the 

20 



306 



ELECTRO-THERAPEUTICS. 



penetrative power of the tube. The cathode stem of the tube should 
extend toward the foot end of the table, to prevent alarming the patient 
by the sparking that necessarily occurs in self- regulating tubes. 









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o/ 7 Exposure. Exposure should be as rapid as possible, other- 
wise the incessant motions of the thoracic viscera will cause a blurred 
shadow. Formerly this obstacle was partially overcome by telling the 
patient to take a deep inspiration and to "hold " the breath. I then took 
a short exposure (5 or 10 seconds), repeating the process five or six times 
in one or two minutes. But this method has been greatly improved upon, 
by the instantaneous process. Radiographs of the thorax have been 
made by Von Ziemssen and Rieder in one second 'of time, by the appli- 
cation of the Rosenthal method. 1 Rosenthal employs a Volt-Ohm appa- 
ratus, with a 60 centimetre coil, an electrolytic interrupter, and a Volt- 
Ohm tube. The time of exposure is shortened by the use of two intensi- 
fying screens, one being placed with its coated side against the coated 
side of the film and the Schleussner film then laid between the intensi- 
fying screens, the coated sides of which are toward the photographic 
film. These are then enclosed in three light tight envelopes. The pa- 
tient lies on his abdomen or back upon the photographic plate, or the 

1 Miinchener medicinische Wochenschrift, 1899, No. 32. 



APPLICATION OF THE X-EAYS. 307 

plate is placed upon the particular part desired to be photographed, and 
the current is opened for a moment and as quickly closed. The plates 
are then removed and developed in the usual manner. l 

Instantaneous Rontgenography. 

The development of more improved and powerful apparatus and 
increased skill in the technic of application have rendered great service 
in the Eontgenography of the thoracic and abdominal viscera. Thus, in 
thoracic Edutgenography we may obtain very sharp outlines of the cardiac 
shadows, with an exposure of one- quarter to one- half second. With the 
Snook transformer I have been able to radiograph an adult chest with the 
above duration of exposure, target at a distance of 24 inches (60 cm.) 
from the plate (Lumiere), without the use of an intensifying screen; the 
penetration of the tube was about Benoist 7 or 8, and thirty to forty 
milliamperes of secondary current were passing through the Crookes tube. 

In Eontgenography of the abdominal viscera I have successfully 
radiographed the normal stomachic movements and also intestinal peris- 
talsis with an exposure of less than one second in thin subjects, which 
has also been carefully observed and studied by my distinguished col- 
league, Dr. Charles Lester Leonard, of Philadelphia, and others. 

Rapid exposures are only justifiable where the part is in motion, as 
the heart, stomach, intestinal tract, etc. In other portions of the body, 
the hip for example, it is better to give a 10-secoud exposure rather than 
a 2-second exposure; there is thus less danger to the life of the tube and 
the production of more detail on the negative is allowed. In lung cases, 
the exposure of 5-10 seconds (while the patient is holding his breath) has 
been sufficient and satisfactory in my practice. 

In a previous portion of this volume (see page 228) I deprecated the 
employment of the fluoroscope, not so much because of its limitations 
but because of the frequent dangers attending its use: and since 
the advent of instantaneous Eontgenography, I can see no logical 
reason why these screen examinations should form any part of the 
Eontgenologist's routine. Notwithstanding this fact, Belot, of Paris, 2 

1 In 1905, during the Rontgen Congress in Berlin, Drs. Rosenthal and Rieder, of 
Munich, exhibited skiagrams of thoraxes which were taken with an exposure of 
one-tenth (^ ) of a second. 

In 1901, Mr. Isenthal (Archives of the Rontgen Ray, vol. v., No. 5) exhibited in 
London instantaneous skiagrams ; in 1904, Dr. Henry Hulst, of Grand Rapids, Mich., 
read a paper before the American Rontgen Ray Society in which he likewise showed 
instantaneous skiagrams of the thorax ; in 1904 1 experimented with different methods 
on the same patient at the Philadelphia Hospital, and arrived at the above conclu- 
sions. See tabulation, page 328. (Transactions of the American Rontgen Ray Soci- 
ety, 1904.) 

2 Official Report of the International Congress of Physio- therapy, Rome, 1907, 
and translated for the Archives of the Rontgen Ray, vol. xii, No. 12, May, 1908. 



308 ELECTRO-THERAPEUTICS. 

has harshly criticized my adverse comments on the subject of fluoro- 
scopic examinations. 

To accurately measure the actual length of exposure employed in 
this instantaneous process Dr. Leonard has devised the following 
photometric method. 1 

The head of a metronome beating half seconds is so placed in the 
lateral field of the Crookes tube that the passage of the current, resulting 
in the production of the rays, will cast a shadow of the oscillating pen- 
dulum over the photographic plate. The exact length of the actual 
exposure can thus be readily deduced. Experience, however, proves it 
difficult to reproduce, at will, exact fractional exposures, and for this 
purpose Dr. Leonard devised and had constructed a focal -plane shutter for 
use with Rontgen tubes. It consists of two metal planes, separated by 
a variable space, which by means of spring propulsion passes with nearly 
uniform velocity before the diaphragm of the tube holder. In employing 
it, the tube is set in action by dropping the switch, the shutter is thcu 
set in motion, and finally the current turned off. By adjusting the tension 
of the spring or the width of the opening, any desired length of exposure 
may be secured and this can be repeated at any future time. Various 
forms of self-acting time-switches have been devised, but they appear 
inferior to the focal-plane shutter because, unlike the latter, the tube does 
not reach its point of greatest activity during instantaneous exposures. 

F. Dessauer, 2 of Aschaffenburg, effects instantaneous Rontgenography 
by generating for a very short time an extremely powerful stream of 
cathode rays in the Crookes tube. During the most brilliant illumina- 
tion of the tube, a single spot on the anode becomes red hot; it is, how- 
ever, not destroyed, as the duration of the current is so very brief. With 
the enormous current thus passing through the tube he is enabled to 
make a Rontgenogram in one one-hundredth of a second or less. He uses . 
an ordinary tube, without water-cooling or heavy cathode, in some cases 
with and in some cases without a reinforcing screen. He uses a com- 
bination of a condenser with a transformer. The instantaneous pictures 
are taken with a single discharge of this apparatus. 

The duration of exposure is not the interval between turning the 
primary current on and off, but the duration of the lighting up of the 
Crookes tube to the time of total extinction of the light. This is gauged 
by a rotating film. 

A motor, the number of whose rotations is known, turns a film which 
is enclosed in paper impermeable to light. Before this film a piece of 
lead-foil having a narrow slot is placed. Through this diaphragm X-rays 
fall on the film. The time of the illumination of the tube is then calcu- 

1 Transactions of the Fourth International Congress of Electrology and Radiol- 
ogy, Amsterdam, September 1, 1908. 

1 Munch, medizin. Wochenschr., May 25, 1909. 



APPLICATION OF THE X-EAYS. 309 

lated by the breadth of the line on the film, after its development, the 
number of rotations of the motor, and the diameter of the circle in which 
the film has been rotating. 

My own preference is not to place too much reliance in switches, 
because the time required to regulate the degree of penetration of the 
tube, the adjustment of the plate to the part, and the other necessary de- 
tails consume so much time that there is constant liability to a change 
of vacuum in the Crookes tube. 

I use an ordinary photographic camera shutter. I have the dia- 
phragm closed in the tube by means of the usual rubber bulb. When 
the vacuum is properly regulated (high penetration), I press the bulb, 
with a resulting exposure that is most accurate. I am experimenting 
with this method, with the hope of producing cinematographic pictures. 

III. Clinical Applications. 

A. DISEASES OF THE BRONCHI AXD LUXGS. 

The X-rays have proved themselves invaluable in diagnosticating 
pulmonary affections and conditions, affording in many cases confirm- 
atory evidence and guiding the practitioner in numerous incipient condi- 
tions into a correct understanding of the pathological changes present. 
Early in the progress of pulmonary diseases, where marked changes are 
not fully in evidence, the usual physical methods employed often fail to 
elicit the proper pathognomonic signs, and it is here that the X-rays serve 
as a most valuable adjunct. 

Bronchitis. Most cases of bronchitis fail to show the normal bright- 
ness of the lung, when free secretion is once established. The character- 
istic clouding is usually limited to the lower two-thirds of both lungs. 
In this affection the excursions of the diaphragm are usually unrestricted, 
except where the smaller bronchial tubes are obstructed by an exudate. 
If the patient is instructed to cough, the secreted material may be expec- 
torated or else temporarily removed from the lower portion of the lung ; 
thus permitting the excursions of the diaphragm to be more perfectly 
restored. In chronic bronchitis, with considerable coughing, there is 
likely to be some dilatation of the right ventricle. If the bronchitis is of 
tuberculous origin, small shadows of the involved areas are usually con- 
fined to the apical regions. In bronchitis associated with influenza, a 
few localized shadows may be discerned, which are really the complicat- 
ing foci of a lobular pneumonia. 

Bronchiectasis. This condition in itself does not produce any shadows 
on the screen or skiagram, unless the adjacent lung tissue is consolidated 
or infiltrated with calcareous substances. When studying this condition, 
the patient should be examined in various positions and from all direc- 
tions. The shadows of bronchiectatic areas are generally found in the 
middle and lower thirds of the lung, and are usually posterior. In un- 
complicated cases of bronchiectasis there are no causes for restriction in 



310 ELECTRO-THERAPEUTICS. 

the movements of the diaphragm. If, however, an emphysema be pres- 
ent, then the excursions will be restricted, and the midriff will be 
observed to occupy a lower position. As a result of a purely bronchiec- 
tatic condition, the heart very rarely changes its shape, size, or position. 
If such a cavity is healing, a considerable quantity of scar tissue is 
gradually developed, which, by contraction, may displace the heart 
from its normal position. In a complicating emphysema the heart is 
displaced by the latter and not by the bronchiectatic disease. If the 
chest is examined before the bronchiectatic cavity has been emptied 
by coughing (the best time for examination of this condition being 
after the patient has been resting in the recumbent position for several 
hours), a distinct shadow corresponding to the cavity is very easily 
seen, followed by a brighter appearance as soon as the contents have 
been evacuated. 

D. B. King 1 furnishes notes on 20 cases studied by the Pontgen rays, 
in addition to the other usual methods of examination. In each instance 
the endeavor was made to detect the presence or absence of (1) dilated 
bronchi. In advanced cases where the bronchi were much dilated, as 
shown by the stethoscope or at autopsy, the Rontgen rays failed to reveal 
their presence. (2) In cases of saccular cavities. Here the rays failed to 
reveal such cavities, probably because of the associated fibrosis of the 
lung. (3) The condition of the lung tissue. Fibrosis of the lung was 
shown by increased intensity of the shadows. (4) The presence of foreign 
bodies. For the detection of foreign bodies in the bronchi, the rays are 
of undoubted value. (5) Study of the action of the diaphragm. This was 
found to be impaired or obscured, depending upon the degree of change 
in the lung. King states that the general value of Rontgen ray examina- 
tion in cases of bronchiectasis is sufficient to warrant its employment on 
more than one occasion, though this may give no further information as 
to the real nature of the case than is furnished by ordinary clinical 
methods. 

Asthma. In asthma the lungs cast a brighter shadow than the 
normal, extending higher up and lower down in the thoracic cavity. 
The position of the diaphragm is observed to be low, and its movements 
much retarded. It is interesting to study a paroxysm of asthma 
while the rays are penetrating the thorax. Such a paroxysm can be 
provoked by injecting cold water into the nasal chambers or by packing 
the nostrils with cotton. During a paroxysm, the lungs look very 
similar to the condition seen in emphysema, differing however from the 
latter in that there is a complete fixation of the diaphragm ; the disap- 
pearance of the paroxysms being evidenced by the restoration of the 
lungs to their natural shadow brightness. The heart occupies a lower 
position and moves less frequently during inspiration than it does 

*The Practitioner, February, 1904. 



APPLICATION OF THE X-RAYS. 311 

normally; the right ventricle is much increased in size, and the outlines 
of the heart are unusually clear cut and sharp, owing to the brightness 
of the lungs during a paroxysm. 

Emphysema. In this affection the pulmonary area is increased, and 
when viewed with a screen it is much lighter than is the normal lung. 
This area of brightness reaches high above the clavicles, and at the same 
time it extends downward, depressing the diaphragm. It is said by some 
that the diaphragm presents two more or less distinct curves (one on each 
side), instead of one large curve as is seen normally. 

During ordinary quiet breathing, the diaphragm appears to descend 
very low in the thorax, though in a forced expiration it ascends to a 
higher level. In pneumonia of one lung there is generally a compensatory 
emphysema of the other, the emphysematous lung appears much brighter 
on the screen than it does in health. The area of the heart when viewed 
with the screen is very nicely defined in emphysema. The dark shadow 
produced by the heart stands out boldly against the much lighter field 
produced by the emphysematous lung. The heart occupies a lower 
position in the chest and assumes a more vertical direction than when the 
lung is normal. In the severer type of emphysema the screen shows 
both the right auricle and the right ventricle to be much enlarged. If 
tuberculosis is a complication, the pulmonary brightness appears spotted 
by irregular darkened shadow areas, usually confined to one or the other 
apex and occasionally involving both. 

Broncho- Pneumonia. In broncho-pneumonia circumscribed shadows 
widely scattered throughout the lungs are observed on the screen, with 
an occasional coalescence of the circumscribed foci. Under such circum- 
stances the shadows are usually limited to the middle and lower lobes and 
are seldom found in the apical regions. The diaphragm frequently 
occupies a very high position, especially during inspiration, with great 
restriction of diaphragmatic movements. If there are no complications, 
the heart does not change its position. Shadows are occasionally pro- 
duced in certain portions by the collapse of the lung tissue ; coughing and 
deep breathing cause their evanescence. 

Pulmonary Tuberculosis. The shadow on the screen of an early 
pulmonary tuberculous lesion is difficult of interpretation. 

Two very important signs that may be elicited by the rays, are a 
slightly restricted diaphragmatic movement on the involved side (Wil- 
liams' sign), and the hazy, darkened, and occasionally emphysematous 
appearance of the lungs. As restricted movements of the diaphragm 
frequently indicate an incipient tuberculosis, they should always be re- 
garded with suspicion. 

To determine the presence of Williams' sign, first view the excursions 
of the diaphragm during ordinary breathing, and mark the highest ele- 
vation on the lower chest by means of an indelible pencil. This tracing 
.should be made on both sides of the chest wall. This quiet breathing 



312 ELECTRO-THERAPEUTICS. 

should be followed by a full, deep inspiration, and the lowest point to 
which the diaphragm descends should be noted in a similar manner, and 
likewise on both sides. 

Two or three deep inspirations successively following one another 
may be necessary to bring out the lowest point to which the diaphragm 
descends. The patient next expires as deeply as possible, and the 
highest point attained by the diaphragm is traced in a similar manner. 
When the excursion from a deep expiration to a deep inspiration is 
diminished on one or the other side, there is also a diminished excursion 
of the diaphragm during ordinary breathing on the affected side. The 
fact that the diaphragm rises somewhat higher on the side of the lesion 
during a forced expiration, should not be overlooked. In advanced 
cases of tuberculosis the side of the diaphragm corresponding to the 
affected side always rises much higher than does the normal side, though 
at the same time the excursion up and down is continually diminished. 
If one lung is partially or wholly diseased, the diaphragmatic excursion 
on the sound side is slightly increased, as compared with the affected 
side. The higher position of the diaphragm taken in advanced cases, 
would seem to be due to a degeneration or shrinkage of the lung tissue 
on the diseased side ; the excursions may also be diminished during 
respiration by adhesion between the lung and diaphragm, or by an 
increased quantity of air entering the organ, resulting from a paren- 
chymatous destruction, etc. An exact study of the diaphragm's move- 
ments is perhaps most satisfactorily conducted by a careful fluoroscopic 
examination. 

The hazy, darkened appearance of pulmonary lesions, especially 
of the incipient tuberculous stage, should always be studied from 
above downward, commencing at the apices. All hazy, darkened 
areas on the screen should be outlined on the skin by an indelible pencil 
or crayon. 

These are usually brought out more distinctly after a full inspira- 
tion. In attempting to detect such a hazy area at the apex or in a lobe, 
the patient should be requested to droop the shoulder on the side under 
examination, so that the shadow produced by the clavicle may be 
lowered out of the field as much as possible. A better view of the 
affected field may be obtained by having the patient stoop forward, 
allowing the rays to enter the thorax at the mid-scapular region, placing 
the screen directly over the supraclavicular space. The examiner should 
compare the light produced by the two apices both during full inspira- 
tion and during deep expiration. The light coming from the tube should 
be so regulated, by increasing or decreasing the distance between the tube 
and patient, that the affected side is only faintly illuminated. When the 
two sides are now compared, the sound side appears slightly brighter 
than the other. The excitation of the tube may be controlled partly, by 
a speed regulator or by a rheostat, but these are seldom required. 



APPLICATION OF THE X-EAYS. 313 

When both apices are involved in a tuberculous process, usually one 
apex is more extensively affected than the other, i. e., there is distinctly 
more haziness on the side most affected. A clouded appearance of both 
apices is indicative of an already advanced form of tuberculosis. In the 
early stages of this disease, an associated emphysematous condition 
of the lungs, occurring in the middle and lower thirds, may be 
demonstrated. 

The value of the X-rays in incipient pulmonary tuberculosis may be 
well illustrated by the reports of the following cases in the service of 
Prof. James M. Anders, which were under my care for a skiagraphic 
examination. 1 

CASE I. S. H., female, married, aged 28 years, cigar-maker, first 
applied at the out-patient clinic of the Medico-Chirurgical Hospital, 
Philadelphia, June 6, 1899, for treatment. A brother died of acute 
phthisis. The patient had had some of the diseases of childhood ; but 
the remainder of her history was negative. Her illness began with 
paroxysmal pains in the prsecordia, and this lasted for a considerable 
period. The day previous to her visit she had expectorated blood, which 
she stated was coughed up ; the quantity of blood was small, bright red, 
and frothy. The abnormal physical signs were an impairment of the 
percussion-note and harsh breathing, with prolonged high-pitched ex- 
piration at the right apex, with absence of the vesicular quality, and 
prolonged high-pitched expirations at left apex ; all signs, however, were 
less marked than at right apex. Microscopic examination of the spu- 
tum gave a negative result. Later an X-ray examination revealed an 
abnormal shadow or marked haziness at the apices of both lungs, but 
more marked at the right. 

CASE II. P. K., aged 29 years, cigar- maker, applied for treatment at 
the out-patient clinic of the Medico-Chirurgical Hospital, November 10, 
1899. The family history is entirely negative as to pulmonary diseases. 
The patient suffered none of the diseases of childhood. He had had 
typhoid fever one and a half years previously, which confined him to bed 
for ten weeks. Since then he had been complaining of persistent gastric 
disturbance, evidenced by eructations of gas and dull pains in the 
epigastrium after meals ; there had been some dyspnoea on exertion, and 
at intervals cardiac palpitation. A few days prior to his first visit, he 
began to expectorate bright-red blood. Subsequently there was neither 
cough nor expectoration. The amount of blood lost did not exceed half 
an ounce. An examination of the throat and larynx was negative, and 
the same was true of a physical examination of the thorax, although the 
chest was of the paralytic or phthisical type. After excluding all causes 
of haemoptysis, except pulmonary tuberculosis, an X-ray picture was 

1 Journal of the American Medical Association, January 12, 1901, and reported by 
me to the American Congress of Tuberculosis, May 14, 1902. 



314 ELECTRO-THERAPEUTICS. 

made. This showed commencing consolidation over circumscribed areas 
on both sides just below the apices. 

CASE III. J. O., aged 14 years, errand boy, was admitted to the 
wards of the Medico-Chirurgical Hospital, November 13, 1899. Father 
died, in his fifty-second year, of heart and lung disease, the precise nature 
of which the patient does not know. One sister is in delicate heallh. 
The lad had had the usual diseases of childhood and a severe illness of 
unknown character a few years since ; had always been in delicate health. 
The present illness began about four weeks before he came under my 
observation. The first symptoms complained of were malaise, headache, 
a slight cough in the evenings and mornings, more or less abdominal 
pains, associated with slight diarrhosa. The evening temperature on 
admission was on the average about 100 F., but abdominal pain, diarrhoaa 
and cough had largely subsided. Physical examination showed a para- 
lytic or phthisical thorax, without any other abnormal physical sign. 
After excluding typhoid fever, latent tuberculosis was suspected ; tuber- 
culin was injected, followed by a positive reaction. An X-ray examina- 
tion was also made by Dr. Kassabian, and showed a slight haziness below 
the left clavicle. (See Figs. 177, 178.) 

Cavitation. As cavity formation begins in the centre of a consoli- 
dated mass, after it has slightly advanced we may observe a lighter field 
encircled by a darker shadow zone. If the outer margin of the cavitated 
mass has been infiltrated with inorganic salts, we may demonstrate on 
the screen a dark, narrow border-like shadow, encircling a larger light 
field. If the cavity is filled with exudative material, there will be no 
light reflex, presenting the appearance of a consolidated mass. This 
would also be true if the entrance to the cavity were located at the upper 
surface. In some instances this fluid can be readily removed by having 
the patient lie down and cough, when the light reflex may be noted to 
again return. A dilated bronchus, with exudative material and consoli- 
dated structure surrounding it, cannot be differentiated from a small 
cavity by means of the X-rays. Where the cavity is small and the wall 
thickened, little or no light reflex may be 'visible on either the screen or 
skiagram. 

As the different pictures of pulmonary tuberculosis presented by the 
screen and skiagram bear a striking similarity to other lung affections, 
the employment of special methods for more accurately determining and 
differentiating the true condition would seem of first importance. Thus, 
Dally, 1 who has made a great many pulmonary examinations by means 
of the X-rays, states that the earliest indication of pulmonary tubercu- 
losis is the unilateral limitation or loss of mobility of the diaphragm. 
Prior to any shadow production (the result of tuberculous involvement) 
the action of the diaphragm becomes gradually lessened on the affected 

1 Lancet, June 27, 1900. 





FIG. 177. Tuberculosis of the right lung (posterior view) , and a photographic tracing of the same. 
The skiagraph shows consolidation of the right apex and right base ; heart is displaced toward the 
right. A, acromion process; Sp, spinous process rf scapula ; Cl, clavicle; C, coracoid process; 1, 2, 3 f 
4, 5' 6, 7, 8, 9, 10, ribs (posterior) ; I, II, III, IV, ribs (anterior). 




FIG. 178. Tuberculosis of the right apex (anterior view). Plate placed in front of chest. The 
chest of the same patient as shown in Fig. 177. The lower cut is a photographic tracing of the above. 
Ab, axillary border of scapula ; Vb, vertebral border ; S.A., superior angle ; RD, right side of the 
diaphragm ; LD, left side ; T.S., triangular space, best seen with the screen against the chest, between 
the heart and the diaphragm (for the diameters of the heart, see page 330) ; C, cavity, which was not 
visible on the posterior view. 



APPLICATION OF THE X-EAYS. 315 

side. After the tuberculous process has advanced to the point of produc- 
ing distinct cloudy shadows within normal lung shadows, the limitation 
of diaphragmatic movements usually becomes more and more evident ; 
it may, however, decrease. 

Cases are reported where marked limitation in the mobility of the 
diaphragm was present when only the apical region of the lung had been 
involved. He further states that the typical shadow of an early pul- 
monary tuberculous process is irregularly mottled, and that such an 
appearance may be simulated by a new growth, but the latter can readily 
be differentiated by the characteristic distribution of the shadow and by 
the peculiar physical signs. A consolidated area produces a shadow of 
moderate density, and this in itself is increased when the adjacent lung 
tissue is hyperaemic. He believes that a caseating process throws a still 
deeper and darker shadow. The appearance of cavities will vary 
according to the size, position, and whether filled or empty. Those empty 
and located at the apical region of the lung are usually transradiant ; 
when filled with pus they may remain unnoticed. In brief, Dally believes 
that the unilateral limitation of diaphragmatic movement as seen by the 
fluoroscope is very often the earliest sign of a beginning pulmonary 
tuberculosis, and that only by the X-rays can pulmonary tuberculosis be 
diagnosticated at an earlier stage than by the other means at the disposal 
of the practitioner. 

Dr. Dally l classifies the quality of the shadow, with the percussion 
note manifested, as follows : 



RONTGEN RAYS. . 



Brightness = Hyper-resonance 

Transradiancy - Normal resonance 

Faint shadow = Impaired resonance 

Dense shadow = Dulness 

Opacity = Absolute dulness 



. . PERCUSSION NOTE 



Vieruzhsky, of the Nikolas Military Hospital, which is devoted 
especially to the treatment of tuberculosis, reports elaborately on the re- 
sults obtained by the various methods of diagnosticating tuberculosis. 2 
He is enthusiastic at the results obtained from the use of the Eontgen 
rays in the diagnosis of the early stages of pulmonary tuberculosis. The 
use of the spirometer as an agent assisting in the diagnosis of this disease 
has not been satisfactory, the figures obtained in the measurement of the 
respiratory capacity of the lungs being uncertain and variable. He is 
well able to realize the deficiencies and limitations of the X-rays, but 
he asserts that skiagraphy offers a means of controlling and confirming 
the data of physical examinations. 

Acute Miliary Tuberculosis. This disease is difficult to diagnose clini- 
cally ; and it is often overlooked by reason of the frequent absence of 
physical signs. The only means then left to the practitioner is by an 

1 Lancet, June 27, 1903. 2 Roussky Vratch, April 26, 1903. 



316 ELECTRO-THERAPEUTICS. 

X-ray examination. In this disease the screen or skiagram presents very 
small darkened shadows, scattered throughout the lung. 

Pneumonia. The various stages of croupous pneumonia may be 
studied both with the screen and the skiagram. A central pneumonia 
which resists detection by the ordinary physical signs may be detected 
by the aid of the X-rays. 

In the stage of congestion there is a uniform dark shadow cast on the 
fluorescent screen ; the result of an increased quantity of blood in the 
affected part of the lung. 

The stage of consolidation presents a still darker shadow, due to the 
increased density. 

A centralized consolidation, not demonstrable clinically, throws a 
shadow on the screen, equally as well as a simple superficial lesion. In 
croupous pneumonia I have observed the middle lobe of the right lung 
to be the one most frequently involved. In this condition the excursions 
of the diaphragm are almost entirely obliterated. In the majority of in- 
stances the right side of the heart is enlarged and displaced to a greater 
or less extent. In some cases involvement is so extensive as to shroud 
the shadow ordinarily cast by the heart. That the cardiac displacement 
is due to the pressure of the dense lung, is demonstrable by the rays. 

The stage of resolution is characterized by the lung tissue returning 
to its former normal structure, and when the shadow cast by the pre- 
viously affected side is similar to that cast by the non-involved side, we 
speak of the organ as having again returned to the normal. The 
shadow of the previously affected area may persist until complete reso- 
lution has occurred, while continued persistence of a shadow in this 
region may indicate a thickened pleura. 

A croupous pneumonia must be diagnosticated from pleurisy with 
effusion, from an acute bronchitis, and from pulmonary tuberculosis. 
The physical signs and clinical symptoms are frequently ill-defined in a 
pleurisy with effusion, so that it may be confounded with a pneumonia. 
In a non-encysted pleurisy with effusion, a dark shadow is thrown on 
the screen, which changes its position with the change of position of the 
patient. In a pneumonia there is no change in the shadow demonstrable 
when moving the patient. In pleurisy with effusion there is a much 
greater displacement of the heart than in an uncomplicated pneumonia. 

Lately I examined a child for an unresolved pneumonia, affecting the 
middle lobe of the right lung. The consolidated spots closely simulated 
a dry pleurisy ; but the latter casts an irregular longitudinal shadow, the 
former circular. 

Atelectasis. The shadows produced correspond to the areas involved 
in the collapse of the lung. If collapse is extensive, the shadows cast on 
the screen are corresponding in size. The excursions of the diaphragm 
are not, as a rule, restricted, and its position is normal. The heart 
does not change in its normal shape, size, and position in a beginning 



APPLICATION OF THE X-EAYS. 317 

atelectasis, though in advanced cases with fibrous tissue formation, fol- 
lowed by contraction of large parts of lung tissue, the heart may finally 
be more or less displaced. The shadows may disappear if the patient is 
instructed to breathe as forcibly as he can. 

Abscess and Gangrene. The exact location of either an abscess or 
gangrene is indicated by a dark shadow. These conditions are usually 
found to involve the lower part of the middle lobe or upper part of the 
lower lobe. As an abscess cavity usually opens internally, and the foul 
material is expectorated, the shadows disappear immediately after the 
cavity is emptied. The excursions of the diaphragm are usually more or 
less restricted, depending upon the size and location of the abscess. The 
position of the diaphragm is normal, and the heart does not change in 
position. If the shadows are multiple, they indicate multiple abscesses. 

B. DISEASES OF THE PLEURA. 

Pleurisy with Effusion. In pleurisy with effusion the diaphragm is 
only slightly, if at all, observed on the screen, depending upon the 
amount of the effusion present. Because of the pressure exerted by the 
fluid upon the adjacent lung tissue, the latter is more dense ; hence the 
fluid throws a dark shadow upon the fluorescent screen, usually denser 
than that cast in any other thoracic condition. 

On changing the position of the patient, the change of level is easily 
discerned by the aid of the fluorescent screen. The upper level of the 
fluid is better seen in the sitting than in the recumbent posture. With 
an abundant quantity of fluid within the pleura! sac, the heart as a 
rule suffers considerable displacement, and far greater when the 
pleural effusion is confined to the left side than when it exists on the 
right side only. 

The shadows of the ribs are usually very faintly shown on the affected 
side above the pleural effusion. As a rule, the heart is displaced prior 
to a downward displacement of the diaphragm. The excursions of the 
diaphragm are usually much restricted, especially when the effusion is 
abundant. Small effusions are often to be detected in the small angular 
spaces on each side between the diaphragm and chest wall. Pleural 
thickenings are not infrequently mistaken for small effusions. Pleural 
adhesions are indicated by limited excursions of the diaphragm. After 
aspiration a clearing up of the previous darkened shadow may be 
noted, the ribs may again be detected, the heart will immediately re- 
sume its normal position, and the excursions of the diaphragm are again 
increased. 

Even though there is only a small quantity of effusion in the pleural 
sac, the lung tissue above the fluid level toward the apex presents a 
darker appearance than the same field of the normal side, this being in 
all probability due to a compression of the lung on the affected side. If 



318 ELECTEO-THERAPEUTICS. 

the right pleural sac is completely filled by fluid, this shadow fuses with 
that of the heart (in the median line or slightly to the right), liver, and 
diaphragm ; hence, all the brightness of the right side is totally lost. 

Prof. Ch. Bouchard 1 was the first investigator to publish observations 
made with the screen in pleural effusions. He demonstrated that the 
X-rays do not pass through the effusion. He also showed that the shadow 
indicated the upper level of the fluid, as confirmed by the ordinary 
methods of physical diagnosis. 

Dally, 2 from his radioscopic study of pleurisy with effusion, concludes 
that the level of the fluid changes with the position of the patient unless 
the quantity of fluid is great and is encysted by adhesions. A puru- 
lent effusion yields a shadow of greater density than a sero-fibrinous 
effusion. The shadow is homogeneous, and in the case of the serous 
effusion the shadow gradually increases in density from above downward. 
However far the heart is displaced to the right, in most cases little 
alteration takes place in the position of the apex relatively to the base. 
Other conditions being equal, the heart is displaced more when the 
effusion is left sided. A somewhat triangular shadow, not normally 
visible, above and continuous with the shadow of the heart and pericar- 
dium is cast by the mediastinum, which is displaced by the lateral 
pressure towards the healthy side of the thorax. 

Empyema. In empyema the displacement of the heart and liver is 
greater than with the same quantity of serous exudate. In pulsating 
pleurisy, the heart movements transmitted to the fluid may be seen as 
diffuse undulations, if the patient remains motionless for the time being. 
According to my experience, the shadow of an empyema on a fluorescent 
screen frequently seems to be a shade darker than that produced in an 
ordinary pleurisy with effusion. This may be accounted for by the fact 
that in an empyema there is usually associated a slight oedema of the 
chest wall over the seat of the exudate. When there is no such cedema- 
tous condition coexisting with an empyema, the shadow cast by the 
retained pus is of the same density as that of an ordinary pleural effu- 
sion. An interlobar empyema (a condition very difficult to diagnosti- 
cate by ordinary means) casts a shadow of the encysted pus on the screen; 
the surrounding lung, above and below, presents the normal brightness, 
provided there is little or no compression of the adjacent pulmonary 
tissue by the enclosed fluid, the movements of the diaphragm are not 
restricted, nor is the heart displaced from its normal position. Dia- 
phragmatic pleurisy is indicative of an involvement of the pleura in 
relation to the diaphragm. There is usually a small quantity of exu- 
date present, which can only be revealed with difficulty, by a careful 
screen examination. Of several cases of this condition that came to my 

1 Archives d' Elect. Medicale, July 13, 1896. 
1 Lancet, February 27, 1904. 



APPLICATION OF THE X-RAYS. 319 

attention, four showed very distinct shadows on the screen. Hemor- 
rhagic pleurisy cannot easily be differentiated from other types of 
pleurisy by the X-rays. 

A pleurisy of the sac with effusion may be complicated with an 
empyema. An empyematous condition of the left pleura would make its 
appearance on the opposite side. In case a pleurisy has been disgnosti- 
cated, complicated by unusual dyspnoea, the examiner should then look 
for an associated empyema of the opposite lung. 

' Pneumothorax. The affected side presents a very bright area and 
of rather large size. The lung tissue is retracted, and the diaphragm 
occupies a lower position than normal ; its movements are greatly re- 
stricted, and occasionally no movements are at all recognizable. The 
cardiac outlines are clearly defined, with a displacement toward the 
unaffected side. 

ffydro-pneumothorax and Pyo-pneumofhorax. In studying the affected 
side of the chest, with the patient in the sitting posture, the fluorescent 
screen shows a very dark area below and a lighter one above. It is best 
demonstrated with the tube behind the patient, the target facing the 
third intercostal space (fourth rib). With the change of position of 
the patient, the fluid may be noticed to alter its level ; the fluid also 
changes its level during respiration, rising during a deep inspiration and 
falling during a deep expiration. 

The excursions of the diaphragm are usually wholly obliterated, 
while it also occupies a very low position, and the heart is displaced 
toward the unaffected side. The pulsations disturb the upper level of 
the fluid area, a condition which may be readily studied by the fluores- 
cent screen. If the lung is examined in the median line and above the 
fluid area, it usually appears slightly darker as a result of compression. 
The degree of displacement of the heart and liver depends upon the 
amount of air and fluid retained in the pleural cavity. An apical tuber- 
culosis of the affected side can very readily be diagnosed, as the 
surrounding field usually appears intensely bright. 

Subphrenlc Abscess. A subphrenic abscess gives a dark shadow in 
the lower part of the thorax, and above it there is a lighter shadow due 
to the presence of air, and, surmounting this, there will be a shaded field 
caused by the compressed lung. The diaphragm occupies a slightly 
higher position with a total abolition of its movements. The heart is 
displaced toward the unaffected side, though this displacement is not so 
extensive as in hydro-pneumothorax. The upper level of the dark area 
changes with the change of position of the patient, and splashing of the 
enclosed fluid may be recognized when the patient is grasped by the 
shoulders and shaken. 

Tumors of the Thorax. Intrathoracic growths cast shadows upon the 
fluorescent screen. These masses are generally circumscribed, and are, as 
a rule, located in the upper part of the chest. Care must be exercised to 



320 ELECTEO-THERAPEUTIC8. 

differentiate these growths from thoracic aneurism ; in the former the 
tumor pulsates with an up and down movement, in the latter, the move- 
ment is expansile. 

If the tumor is not too large there is no restriction in the excursions 
of the diaphragm. The heart is generally slightly displaced. Small 
calcified lymphatic and bronchial glands are often noticeable. 

Enlarged Glands. Any enlargement of the thoracic, mediastiual, or 
bronchial glands is easily shown on the fluorescent screen or skiagraph. 
As the bronchial glands are usually first involved in tuberculous condi- 
tions of the lungs, a few authorities have successfully demonstrated a 
slight enlargement of the glands in the incipient stage. Any glandular 
enlargement should be viewed suspiciously as the beginning of an adja- 
cent tuberculous involvement. This condition is best viewed on the 
screen by having the rays traverse the body diagonally. 

IV. Application of the X-rays to the Circulatory System. 

In fluoroscoping the normal heart in the anterior view, we observe 
the shadow of the heart and aorta. These shadows are due to the opacity 
of the contained blood and to the superimposed shadows of the verte- 
brae and sternum. The posterior view shows the same structures in their 
posterior aspects. The anterior view, however, is preferable, as the heart 
being nearer the chest wall allows of a clearer shadow on the fluoroscope. 
Fluoroscopy is preferable to skiagraphy in the study of the circulatory 
system, as with it we can observe the cardiac cycle, the aorta and the 
movements of the diaphragm, from various positions. 

A. FLUOROSCOPIC EXAMINATION OF THE NORMAL HEART. 

The heart may be examined with the patient in the sitting, standing, 
or recumbent posture. The heart when viewed by the screen occupies a 
characteristic position in the thorax, when the patient is seated on a stool. 
During expiration it rests on the diaphragm, its long axis forming an 
acute angle with the imaginary median line of the thoracic cavity. In 
inspiration the heart moves downward and toward the median line ; the 
right border of this organ is plainly seen to the right of the sternum, the 
larger or left part of the heart is seen to the left of the sternum, i.e., 
the long axis of the heart forms with the median line during expiration 
a less acute angle than during an inspiratory effort. During inspiration 
the transverse diameter of the heart is slightly decreased in length, at 
the same time the number of pulsations are lessened. In expiration, 
after the diaphragm has discontinued tugging on the heart, the transverse 
diameter is again increased, as is al-so the amplitude of its pulsations. 
The general contour of the organ can be more easily seen during inspira- 
tory periods than in the expiratory, because the lungs, being filled to their 
capacity, are more transparent to the rays, thus offering a more striking 



APPLICATION OF THE X-RAYS. 32 i 

contrast. The cardiac outline may be readily differentiated by means of 
the ingenious artifice of Dr. Disan. 1 By this method the outline of a 
normal heart is traced on the chest by fixing with adhesive strips a copper 
wire. A fluoroscopic examination is then made in the following way : 
At first the greatest strength of current obtainable from the apparatus 
is turned on. The observer looks through the fluoroscope and gets the 
chief landmarks of the chest, such as the scapula, ribs, spine, diaphragm, 
and upper convex border of the liver, the wire being at the same time in 
full view. The current is now reduced until the heart becomes more dis- 
tinctly visible. The fluoroscope is applied to a spot marked at the left 
of the spine, corresponding to the fourth intercostal space in front of the 
chest. Any alterations in the shape of the heart can thus be easily 
demonstrated. 

The shadows of the pulmonary vessel and in many instances the vena 
cavss can be recognized if the chest is made to assume a position diagonal 
or oblique to the screen and tube. 

The pulsations of the heart are less in number during a deep inspira- 
tion than in expiration, or even in the ordinary quiet breathing. These 
pulsations are lessened during a deep inspiration and by increase of the 
air pressure upon the heart, i. e., the pressure from the pericardium, 
which is made more taut during the descent of the diaphragm. 

TJie Orthodiagrapli. This instrument was devised by F. Moritz, of 
Munich. 2 (Figs. 179 and 180.) Its purpose is the bringing out of any 
object in its exact size and without distortion. By it the size and shape 
of all the recognizable internal organs, as well as other parts of the body, 
can be determined. As the Rontgen rays are propagated from a point 
on the anodal field in straight lines radiating in every direction, and as 
the image of a body projected on a phosphorescent screen or skiagram is 
a silhouette, the outline of the object presented coincides with the places 
where the rays coming in contact with the edge of the body impinged 
upon the screen. This outline, therefore, is the periphery of the base 
of a cone, whose point coincides with the luminous spot of the anti- 
cathode. As the object to be projected is located between the vacuum 
tube and the screen, the image on the latter will be magnified, the degree 
of magnification being dependent upon the ratio of the distance of the 
object from the image plane and the distance of the object from the 
vacuum tube. The image projected by a vacuum tube, so far from re- 
cording the true dimensions and shape of the object, will show the latter 
more or less magnified and distorted. In order to obtain the true shape 
and size of the object, the rays touching the body and forming on the 
plate an image of its outlines must be made parallel and strike the 
plate at right angles, i.e., the projection from a centre must be 

1 Dominion Medical Monthly, February, 1897. 

2 Berlin Allgemeine Electricitats Gesellschaft, and Munch, med. Wochenschrift, 
April 10, 1900. 

21 



322 ELECTRO-THERAPEUTICS. 

replaced by a projection that is parallel. "With the orthodiagraph, pro- 
jections true in shape and size are obtained in any desired position of 
the drawing-plane. 

The luminous screen which also carries the drawing stylus is con- 
nected with the Rontgen tube by a U-shaped frame. This frame, made 
up of a number of jointed sections, permits of any desired adjustment of 
the screen with the tube. A rod extending from the screen is longi- 
tudinally adjustable in a split sleeve on the end of a tube lying parallel 
with the axis of the drawing stylus. The tube is provided with a tele- 
scoping member, on the projecting end of which a second split sleeve is 
adapted to slide. This screen is formed on the end of an arm which is 
thereby supported at right angles to the telescoping member. The clamp 
holding the tube has a ball-and-socket connection with a member which 
may be adjusted to any position along the arm. When properly adjusted 
the propagating joint of the X-rays should lie on an extension of the axis 
of the stylus. This may be done approximately by adjusting the tube 
clamp and other members of the U-shaped frame. In order to obtain a 
more perfect adjustment of the tube, i. e., such adjustment as would per- 
mit working with accurate perpendicular rays, the screen may be ad- 
justed in one plane, by moving its supporting rod longitudinally in the 
split sleeve above referred to, and in a plane at right angles thereto, by 
adjustment of the screen within its holder. By noting the shadow cast 
on the screen by the end of the stylus projecting there through, the oper- 
ator can readily ascertain when accurate adjustment has been obtained. 

Parallel movement of the tube with the screen is obtained by means 
of two levers, one pivoted to the other. A lever which supports at one 
end the U-shaped frame is hinged to a second lever, which in turn is piv- 
oted to a bracket on the end of the supporting column of the apparatus. 
Each lever is provided with a counter- weight, movable along its outer 
arm, and these weights serve to hold the parts in equilibrium. 

The bracket just mentioned also carries a rod, to which the drawing 
frame is attached by means of a universal joint. The drawing frame is 
adapted to be covered with heavy bristol- board, held therein by holders 
at the sides, and on this surface the drawing stylus is softly pressed by a 
spiral spring. 

Now the whole system so far described is movable around the axis 
in the head of the main supporting column, and may be clamped in any 
position by means of a milled nut ; an additional fixing lever may be 
grasped to prevent this system from suddenly dropping or loosening the 
nut. At the same time, the accurately vertical and horizontal position 
of the system is indicated by a spring catch. The length of the support- 
ing column is such that on turning the system round its axis into a hori- 
zontal position, the drawing plate will just be at a convenient distance 
above a person lying on an ordinary table of about 30 inches in height. 
The heavy base plate is provided with four rollers allowing of the 



APPLICATION OF THE X-RAYS. 



323 



drawing apparatus being readily moved. By operating special screws, 
these rollers may be removed, and the apparatus placed on the points 
of the screws, which in addition will allow of the column of the 
apparatus being given an accurately vertical position even on oblique or 
uneven floors. 

When a drawing is to be made directly on the body, the bristol-board 
is removed from the drawing frame, and a dermatograph stylus should 
be inserted into the drawing stylus, instead of a pencil. The drawing 




FIG. 181. Levy-Dorn's orthodiagraph for the standing position. 

frame is provided with three pencil-holders, or " plotters," as they are 
called, which are movable in the plane of the screen or in that of the 
drawing plate, and provided with scales in both co-ordinates ; the posi- 
tion of a person with regard to the central ray may be thereby ascertained, 
so that on the examination being repeated the same position of the per- 
son may be accurately secured. A fourth auxiliary plotter has been pro- 
vided with slides on a scale projecting from the extended axis of the 
lower supporting lever. 



324 ELECTRO-THERAPEUTICS. 

In addition to reproducing the true shape and size of organs, the 
apparatus may be advantageously used to ascertain the depth of foreign 
objects. This can be done by measuring the apparent diameter of the 
object when the Rontgen tube is stationary, and then ascertaining the 
actual shape of the body by means of parallel movement of the drawing 




Reiniger.Gebberh StSchall, Erlangen. 
FIG. 182. Levy-Dorn's orthodiagraph for use in the recumbent posture. 

stylus and the tube. Now if a I is the apparent length of a foreign body, 
r I its real length, D the distance of the anticathode of the tube from the 
luminous screen, and d the distance of the object from the anticathode, 

ft r 1 x D 

the formula ^ will give the true distance of the foreign body 

from the luminous screen. 

The Levy-Dora orthodiagraph is shown in Figs. 181 and 182. The 
advantage of this instrument lies in the fact that during the examina- 
tion of the heart the operator measures the vertical and horizontal axes 
on the scales. 

B. SKIAGRAPHIC EXAMINATION OF THE HEART. 

The heart can be skiagraphed with the same technic as is applicable 
to the lung, but the former requires more precision in the position of the 
patient, tube, distance, etc. The patient may be seated on a chair and 
the plate placed either over the chest (sternum), in the anterior or 




FIG. 182A. LUNGS AXD HEART (erect dorsal position.) This position may be more comfortable to 
some patients. The ventral view may be obtained by reversing the patient's position. In taking stereo- 
scopic Rontgenograms of the chest, it will only be necessary to place the plate-changing box into the 
grooves of the leaflet, and tube holder will be displaced by pulling out the chain, thus changing the 
position of the anode 2J4 inches or 6 cm. 



APPLICATION OF THE X-RAYS. 325 

ventral view, or to the back (posterior view). Ask the patient to raise 
both arms, in order to remove the shadows of the scapulae from the 
thorax. Centre the anode of the Crookes tube over the level of the third 
rib in back and one inch below the upper end of the sternum in the 
median line. The distance of the anode from the plate should be from 
25 to 30 inches (63-75 cm.). An anterior and posterior skiagraph should 
be made at the same time, noting that no abnormality or deformity 
exists. If the tube is placed in an oblique position the shadows will often 
mislead and confuse. Anterior and posterior oblique (right and left) 
skiagraphs should also be taken, in order to study mediastinal tumors, 
and the arch of the aorta. The time of exposure should be as short 
as possible, correspondingly to the cardiac cycle. Two methods of 
skiagraphing the thorax are presented in Figs. 183 and 184. 

M. Guilleminot, of Paris, invented an instrument by which he can 
make cinemato-radiographic pictures. The exposures can be made either 
during inspiration, expiration, or during the ascent and descent of the 
diaphragm ; and also during the systole and diastole of the auricles and 
ventricles. I have made stereo-skiagrams of the thoracic organs of 
young thin subjects, which have yielded for scientific study the true 
perspective and relief effects of the heart, aorta, sternum, and vertebrae ; 
such results are of clinical worth in studying aneurisms and cavitations. 

Telerontgenography. 

The determination of the size of the heart is an important matter 
to every Rontgenologist. The difficulties which beset the attempt to 
ascertain the true size of this organ are well known among students in 
this field of endeavor. 

Rontgen rays diverge from a single point and the position of the 
heart is at some distance from the surface of the chest, and hence from 
the fluorescent screen or photographic plate ; thus it follows that the 
projection of the heart will be more or less magnified. To correct this 
error, Professor Moritz devised the orthodiagraph (see pages 321-324). 
But the latter instrument has the disadvantage that the outline of the 
heart must be drawn by hand. We must, therefore, allow for some error 
in using this instrument, and the results can only be assumed to be 
correct within some five millimetres (one-fifth of an inch). 

In ordinary examinations the screen or plate is placed on the chest 
some 20 to 30 inches (50 to 75 cm. ) from the anode. The magnification 
resulting increases the cardiac width from the median line to the left 
outer margin of the heart by some 4 to 6 inches (10 to 15 cm. ) ; for it is 
a well-known fact that when a shadow of a body is projected on a plane, 
the size of the shadow will approximate more nearly to the size of the 
object as the distance from the source of light increases 5 and since the 



326 ELECTRO-THERAPEUTICS. 

heart is not placed symmetrically, the magnification of the organ is 
associated with a shadow distortion. 

The study of telerontgenography, or radiography at a distance, first 
engaged the attention of Dr. Alban Koehler of Wiesbaden, 1 who observed 
how errors in the size of the heart are affected when the Crookes tube is 
placed at a distance of 5 to 7 ft. (1^ to 2 metres) from the photographic 
plate. Thus, he assumes that the apex of the heart is 2 inches (5 cm. ) 
below the surface of the chest and 3 inches (7 cm.) from the median 
sagittal plane of the body ; now, if the distance of the anticathode is 55 
inches (1.4 metres), then the increase of cardiac shadow at the left apex 
will not exceed more than approximately 1-10 inch (2.5 mm. ) Of course, 
it is assumed that the anticathode is placed vertically over the median 
line of the body, nud that the normal ray is at right angles to the anterior 
surface of the body and to the photographic plate. With a focus dis- 
tance of 78 or 80 inches (2 metres) the error will be reduced to 1.7 mm., 
or about the width of a mark of a dermatological pencil. Mathematical 
considerations prove that, in telerontgenography of the heart, the meas- 
urements may be accepted as substantially correct. 

There is no limit to the distance at which the Crookes tube may be 
placed, provided that there is at hand an installation of sufficient power 
to afford the requisite degree of intensity of irradiation. 

To carry out long-distance skiagraphy with success, Koehler does 
not believe it absolutely essential to use a very powerful installation. He 
asserts that in his first experiments with telerontgeuography, 2 the appa- 
ratus that he employed was driven by accumulators having a potential 
of only 24 volts." 

Koehler advocates the taking of a Rontgenogram with the patient 
in the erect posture and during deep inspiration. Those suffering from 
dyspnoea must be radiographed during quiet breathing; in the latter 
class of cases the outline of the heart is not so sharply defined, but with 
the tube at such a distance the contour is usually sufficiently clear. 

The Crookes tube should be placed in the median sagittal plane of the 
body, at the level of the sixth spinal process. With thin persons tele- 
rontgenography may also be successfully carried out with lateral illumi- 
nation. 

Koehler' s technic is as follows : 

He employs a Ruhmkorff coil of 16 inches (40 cm.) spark-gap; to 
this is attached a condenser. His focus tube is of the regulating mono- 

'Archives of the Rdntgen Ray, vol. xii, No. 92, March, 1908. 
2 (Ibid.) 

'Wiener Klinische Rundschau, April, 1905. Deutsche medicinische Wochen- 
schrift, 1908. 



APPLICATION OF THE X-EAYS. 327 

pole variety with a rotary break witli rubbing contact (Hirschmaim 
model), a voltage of some 32 volts, obtained from accumulators attached 
to the public main, current 5 to <> amperes; the focus tube having a pen- 
etration of from 6 to 8 on Benoist's scale. 

Except when the patient is of slender build, he employs an intensi- 
fying screen, of very fine grain. Since it is quite impossible for the 
plates to be over-exposed, the developing solution should be fairly con- 
centrated, and the negative may be intensified if necessary with perchlo- 
ride. Length of exposure varies from 15 seconds for those of slender 
build to 30 seconds for stouter patients. 

Because of the dangers of the fluoroscope I do not recommend the 
employment of orthodiagraphic methods. But in its place I would 
strongly urge the use of teleroutgenography. By the latter method in 
conjunction with stereo -rontgenography of the chest, I have been most 
successful in studying cardiac and pulnionic affections, especially with 
the instantaneous method. 

Size and Measurement of the Heart. The size of the heart varies 
under many different circumstances : the stature of the person, age, 
weight, individual peculiarity, etc. These variations in size, I have re- 
peatedly noted in Rontgeuographic examinations. 

According to Abrams, 1 with the screen at about 29^ inches (75cm.) 
from the tube and with the target directed toward a point where the 
median line is crossed by the fourth rib, the normal heart is seen to ex- 
tend from the median line lf\ inches (3 cm. ) on the right side and 3^ 
inches (8.5 cm.) on the left side, the total width of the heart being about 
4 inches (or 10 cm.). 

Mobility of the Heart. Silbergleit * describes a case in which the 
entire heart was capable of lateral displacement of several inches by a 
change from the left lateral to the right lateral position. The patient 
was a man of twenty -four years who came under observation for gastro- 
enteritis and a moderate degree of chlorosis. He had no subjective 
symptoms referable to the heart, and in the standing position or when 
lying on the back physical examination of the organ was negative. 
When lying on the left side, however, the apex beat was three centi- 
metres outside of the mammary line, and the right border one centimetre 
to the left of the left sternal margin. When on the right side, the apex 
beat appeared close to the left sternal margin and the right border was 
correspondingly displaced. This case is of scientific value, in that the 
abnormal mobility is only an index of an existing cardiac lesion. 

Sears 3 states that Determann's experiments, made with the X rays 
and by percussion, demonstrated the mobility of the heart with change 

'Journal of the American Medical Association, May 3, 1902. 

2 Medical Record, June 20, 1903. 

3 Medical Standard, January 1, 1901. 



328 



ELECTRO-THERAPEUTICS. 



of position. In the healthy individual turning on the left side produced 
an average displacement of 2J centimetres to the left and 1 centimetre 
upward ; turning on the right side occasioned a change of 1 J centimetres 
to the right and about J centimetre upward. In some cases the displace- 
ment was quite small, in others as much as 6? centimetres to the left and 
4 centimetres to the right, without distress to the subject. These greater 
movements were found to occur, as a rule, in flabby and ill-nourished 
individuals and in those whose abdominal organs were loosely anchored. 
It was observed that women usually have more freely movable hearts 
than men, especially after childbearing or from the use of tight stays. 
Children have little signs of it, the newborn scarcely any, and in old 
persons it is slight. Individuals of sedentary habit and feeble muscular 
development are especially subject to the condition. The physiological 
effect of the full stomach is noted, and also anything which tends to 
elevate the diaphragm. During the latter part of pregnancy the heart is 
much pushed up and is compressed, thus showing very little mobility. 
Immediately after delivery, however, the highest grade is found, and the 
apex may be displaced on the left side 9 centimetres from its original 
position. 

MOEITZ TABLE. 1 

Healthy Adult Man (Age 17 to 56) . 







o> o 

.a ** 


& 2 












_. o> 

G a 


ss 


i 











8 3 


3 






a 


HEIGHT OF THE 
PERSON 


DIMENSIONS 


W C 
" c3 *j 


o ^ 
c S +* 


i 



II 


$ 






lit 


ISS 


60 


i 


! 






Q 


ft 





H 


c 






cm. 


cm. 


cm. 


cm. 


cm. 


153-157 cm. or 


average 


4.4 


7.9 


13.0 


10.2 


98 


5 ft. 9 inches 


maximum 


4.8 


8.0 


13.5 


10.5 


100 


5 ft. lOi inches 


minimum 


4.0 


7.8 


11.5 


10.0 


80 


161-169 cm. or* 


average 


4.4 


8.3 


13.4 


10.5 


102 


6 ft. inches 


maximum 


5.0 


9.3 


14.5 


10.8 


108 


6 ft. 31 inches 


minimum 


3.5 


7.5 


12.8 


9.0 


87 


171-178 cm. or 


average 


4.6 


8.8 


14.0 


10.3 


100 


6 ft. 4 inches 


maximum 


5.9 


9.7 


15.3 


11.0 


126 


6 ft. 7| inches 


minimum 


3.0 


7.8 


12.5 


9.0 


92 



Displacement. In this condition the heart may retain its normal 
shape, only changing its position. The most frequent cardiac displace- 
ment is dextro-cardia, which is a congenital malposition. In the acquired 

'H. Gocht, " Handbuch der Rontgenlehre," " Erwachsene gesunde Manner 
(von 17 bis 56 Jahren)." 



APPLICATION OF THE X-RAYS. 329 

forms of malposition the heart may be displaced low down iu the chest, 
the pulsations may be felt behind and below the lowermost extremity of 
the sternum, or it may be placed to the right of the sternum or the left 
outside the left nipple line, these facts being confirmed at the same mo- 
ment with the fluoroscope. Fluid in the left pleural sac causes the heart 
to be pushed toward the right side, while exactly the opposite condition 
exists when the right pleural cavity is so affected ; but in dry pleurisy the 
adhesions may draw the heart toward the affected side. Distention of 
the pleural cavity by gas, as seen in emphysema, also causes a displace- 
ment either to the right or the left, depending upon the cavity that is 
involved. An increased elevation of the diaphragm causes the heart to 
assume a position on its long axis so that the right ventricle is pulled to 
the anterior position, the chief feature of recognition being the increased 
distinctness of the right side of the heart when the chest is examined from 
behind. 

Cardiac Atrophy, Hypertrophy, and Dilatation. These conditions are 
revealed by a screen examination. Atrophy presents a small size of the 
organ. In hypertrophy or dilatation of the left ventricle, the apex has 
changed from its normal position, the shadow area is increased, and the 
clear space normally existing between the heart and liver (as seen on a 
deep inspiration) is diminished in size or has totally disappeared. If the 
right ventricle is increased in size the base usually appears more or less 
drawn down and the long axis assumes a more nearly horizontal position. 
Abdominal distention, with either fluid or gas, causes an elevation of the 
diaphragm, hence another cause for change in the position of the heart. 
I have often noticed that the heart atrophies in advanced cases of tuber- 
culosis. In a pneumonia, displacement is usually toward the unaffected 
side ; in an extensive emphysema the heart naturally occupies a posi- 
tion lower than normal. Aneurisms, new growths, and adhesions are 
among the other causes of cardiac displacement. Thorne 1 observed a 
heart to shrink after its exposure to the Eontgen rays for thirty minutes. 
In one case, the heart had shrunken in its long axis some lj ^ to 2 inches 
(4.5 to 5 cm.), while in its transverse diameter the contraction amounted 
to 1J inches (4 cm.). Experiments in this connection have been con- 
ducted on dogs, the results in general showing a considerable shrinking. 

Care should be taken when fluoroscoping the heart to differentiate 
between true atrophy and displacement. In the Schott treatment of 
heart disease, the attendant studies the patient's heart before and after 
each treatment. I have never observed any change in the size of the 
heart except an alteration in the pulse rate noted in certain neurotic cases. 

Acute Dilatation of Heart. F. Moritz 2 stated that orthodiagraphy has 
failed to confirm the occurrence of any appreciable acute dilatation after 

1 British Medical Journal, 1896, vol. ii. p. 1238. 

2 Miinchener medicinische Wochenschrift, lii., No. 15, April 11: " Acute dilatation 
of the heart due to diphtheria." 



330 ELECTKO-THERAPEUTICS. 

physical exertion, after hot baths, the injection of alcohol, narcotic or 
other medication ; chloral, chloroform, caffein, or kola. It has revealed, 
however, that the outline of the heart is smaller in the upright position 
than when the subject reclines. He believes that an interesting field 
for research is opened by orthodiagraphy of the dilated heart, whereby 
we can study the influence exerted upon it by rest in bed, digitalis, 
carbonated baths, electric baths arid gymnastics, etc. H. Dietlen 1 
states that he has examined 47 out of 65 patients suffering from 
diphtheria with the aid of the Moritz orthodiagraph, the subjects reclin- 
ing, and he found that 20 of these 47 presented evidences of myocarditic 
phenomena. In 15 of this group (75 per cent, of the cases of endocar- 
ditis and 32 per cent, of the total number), dilatation of the heart 
was unmistakably apparent when examined with the orthodiagraph. 
Even extreme degrees of dilatation are liable to retrogress, so that the 
prognosis is not necessarily bad. 

Examination of the Heart. Kraus 2 has analyzed the findings of radio- 
scopy of the heart in health and disease. He asserts that the shades of 
difference l>etween the heart shadows cast in cases of various valvular 
affections are of greater diagnostic importance than dilatation of the 
heart alone. These differences in shadows are due to changes in the 
shape of the various sections of the heart, the immediate consequence of 
the valvular defect. The consecutive hypertrophy of the musculature 
and passive dilatation naturally reinforce and emphasize, as it were, the 
differences in the outline. This is especially marked in the left convex 
protrusion of the so-called left middle arc in case of mitral defect, also in 
the varying behavior of the left lower arc with mitral insufficiency and 
pure mitral stenosis, and, finally, in the outline of the shadow as it 
spreads to the right, in case of aortic and mitral defects. Eadioscopy 
of the heart after artificial distentiou of the stomach is very instructive. 
The presystolic pulsation of the right auricle can be distinctly distin- 
guished from the contraction of the ventricle. Two and sometimes three 
contractions of the auricle to one of the ventricle are sometimes noted. 
Intermittence of the heart is seen to be by no means always identical 
with intermittence of the pulse. In cases of tachycardia and bradycardia 
radioscopy throws light on many hitherto unexplainable processes, 
especially those of nervous origin. 

Pericarditis (Pericardial Effusion). If an enlarged shadow is cast by 
the cardiac area, it indicates hypertrophy, or a pericarditis with effusion. 
If there is presented a movement of the left border of the heart's shadow, 
it indicates enlargement. In case no such pulsation is demonstra- 
ble, pericarditis with an effusion should be surmised. The shadow of a 

'Miinchener medicinische Wochenschrift, Hi., No. 15, April 11, 1905: ''Acute 
dilatation of the heart due to diphtheria." 

'Deutsche medicinische Wochenschrift, Berlin and Leipsic, xxxi., No. 3, January 
19 ; Journal of the American Medical Association, June 10, 1905. 



APPLICATION OF THE X-RAYS. 331 

pericardial effusion is rounded or circular, while that of hypertrophy is 
more or less pyriforni. In most cases the shadow cast by an effusion is 
not so dense as that produced by the heart muscle itself, so that in view- 
ing the shadow field we may find a variety of shades ranging from a 
slightly lighter field to one that is dark. A change in the upper level of 
the shadow may occasionally be noticed by changing the position of the 
patient. 

Aortic Aneurism. Cases of aneurism, unsuspected and unrecognized 
by the attending physicians, have been revealed by careful fluoroscopic 
and skiagraph ic examinations. While aneurisms are sometimes un- 
detected by X-ray examinations, a large number are supposedly diag- 
nosed that in reality do not exist ; an early diagnosis, therefore, is most 
important. The prognosis of aneurism was formerly regarded as most 
unfavorable, but in the light of recent knowledge the so-called "com- 
mencing aneurisms of the aorta" have been shown to remain often 
stationary, and that they do not necessarily proceed to a fatal termina- 
tion. They can always be studied during treatment as to their size, 
position, pulsation, etc. 

Fluoroscopic examinations are preferred by most operators because 
they are enabled to see the tumor or pulsating condition and because the 
condition can be examined from different angles and positions. Both 
methods should be employed, although I never use the fluoroscope. 

The skiagraphic examination is identical with the technic described 
on diseases of the lungs and heart. 

The shadow of the normal aorta (when viewed anteriorly or posteri- 
orly) is almost totally obscured by the superimposed shadows of the 
sternum and the vertebral column, with the exception of a small shadow 
to the left, cast by the left lateral a rtic bulge. 

Aneurisms of the ascending portion of the arch of the aorta, being 
nearer to the anterior wall of the chest than the posterior wall, cast 
shadows extending to the right of the sternum and above the heart. 

Aneurisms of the descending portion of the arch of the aorta 
(Figs. 185 and 186) usually cast shadows to the left of the sternum, which 
are nearer the posterior than the anterior wall of the chest. If the 
aneurism is very large, the shadow will extend to both sides of the 
sternum. 

Aneurisms of the transverse portion of the arch of the aorta will cast 
shadows slightly to the left, and if large the shadow observed will extend 
up to the neck. This detection, however, is very difficult, and requires, 
in addition to anterior and posterior examinations, left lateral and right 
lateral oblique examinations. 

Beginning or diffused aneurisms are difficult of diagnosis, especially 
so in corpulent individuals. Gocht ! declared that by means of the 

1 Lehrbuch der Rontgenuntersuchung, Stuttgart, 1898, p. 199. 



332 ELECTEO-THEEAPEUTICS. 

Eontgen rays it was possible to determine the presence of an aneurism 
where doubtful symptoms were manifested. 

Dumstrey and Metzner J urged considerable caution in reaching con- 
clusions regarding the existence of aneurisms by means of the Eontgen 
rays, especially where physical signs or symptoms failed to be elicited ; 
they furthermore believe that mediastinal tumors may give rise to the 
same appearance. 

Drs. Geo. Pfahler and Jos. Sailer* assert that, after a careful com- 
parative study with X-ray diagnoses and post-mortem examinations of 
supposed aneurisms, they found that the tortuosity of the aorta was 
in many instances confounded with the existence of aneurisms. 

Dr. G. H. Orton 3 says that, "In some cases, even with these four 
examinations, the shadows of the aorta cannot be satisfactorily inspected, 
owing to complications which may mask it." 

Of late, I am making stereo-skiagrams of the chest, and find them 
valuable in differential studies involving the aorta, heart, and lungs in 
their respective relations to each other and to the bony thorax. 

In many cases of small aneurism, the oblique method of examination 
should be employed. This has been well described by Holzkuecht 
andB6clere: 4 "It consists in rotating the patient so that the rays 
penetrate the chest obliquely. If the screen is placed on the left of the 
patient and the tube on the right side, the pericardial shadow is bounded 
by two clear spaces ; the retrosternal in front, and the retrocardiac 
behind. In this position the inferior parts of the ascending and descend- 
ing aorta can be seen, but the arch is hidden by the shadows of the 
shoulder muscles and vertebral column. 

"Now if the patient is rotated so that the rays penetrate the chest 
at an angle of 45 forward and from left to right, the best position 
is obtained. In this position the cardiac shadow is angular, the base 
continuous with the diaphragm, the superior angle prolonged into a 
vertical offshoot, caused by the superimposed shadows of the ascend- 
ing and descending parts of the arch. In this position many cases 
of supposed aneurism which show the marked aortic bulge in the 
antero-posterior examination are shown not to be true aneurisms. In 
suspected cases the examination is not complete until this method has 
been employed." 

Another important sign in the diagnosis of aneurism, first pointed 
out by Walsham, consists in a change in the position of the heart, which 
comes to lie more transversely, the right side being apparently pushed 
down by the aneurism, with a tilting upward of the apex. Orton, like- 
wise, regards the position of the heart as a very valuable and constant 

1 Fortschritte auf dem Gebiete der Rontgenstrahlen, vol. i. 

1 The American Journal of the Medical Sciences, October 1, 1903. 

* Archives of the Rontgen Ray, August, 1905. 

4 Archives of Physiological Therapy, October, 1905. 




FIG. 185. Aneurism of the descending aorta (posterior view). Plate applied against the back 

of the chest. 




FIG. 186. Photographic tracing of the same. Heavy lines, outlines of normal heart ; dotted lines, 

dilatation of the descending ( D < ) aorta. Observe the horizontal position of the heart, due to 

aneurismal pressure. A >- , ascending aorta ; T -< , transverse aorta. 




3 I 

g .3 




111 



cS <-> 

S - u 

c 3 



t -o s 



lit 

Mi 



10 5| 

0) O 3 



APPLICATION OF THE X-RAYS. 333 

sign. There are shadows that may exist either to the right or left of the 
sternum which may be confounded with the diagnosis of aneurism. 

1. Dilatation of the aorta (not aneurismal). 

2. Displaced aorta (dislocated). 

3. Enlarged glands. 

4. Neoplasms. 

5. Pulsating empyenia. 

1. Dilatation of the Aorta (Fig. 187). This condition is often con- 
founded with aneurism ; the shadow cast will be on either side of the 
sternum, the diagnostic point being that this pulsating shadow will dis- 
appear between the pulsations (the diastole) ; because with the contrac- 
tion of the aorta the shadow thrown will be smaller, or it will be com- 
pletely hidden by the shadows cast by the sternum and vertebral column. 
In this differentiation the fluoroscopic examination will prove more 
useful than will the skiagraph. 

2. Displaced Aorta. This condition usually appears to the left of 
the spinal column, a pulsating shadow being evidenced as far as five or 
six inches to the left of the border of the sternum. This is a much 
greater area than will be projected by the aneurism of the arch. 

Abnormalities of the thorax and spine should be excluded. 

3. Enlarged Glands. Enlarged lymphatic and bronchial glands 
cast scattered shadows, with absence of the characteristic expansile 
pulsations. 

4. Neoplasms. Mediastinal growths, i. e., carcinoma and sarcoma, 
can be differentiated, in that the latter cast darker or denser shadows, 
the edges are hazy, indistinct, and uniform, and by the absence of ex- 
pansile pulsations. Care should be exercised not to overlook transmitted 
pulsations. 

5. Pulsating Empyema. Pulsating empyema and other intra- thoracic 
abscesses will be differentiated by the history, their location, and form. 

Aneurisms of the abdominal aorta cannot be well demonstrated in 
corpulent persons, owing to lack of contrast with the surrounding tissues, 
as the shadows of the aorta and vertebrae superimpose, when skiagraphed 
in either the ventral or dorsal positions. Lateral and oblique positions 
are always advisable in skiagraphing this condition. 

Atheroma. Atheroma and calcification of the blood-vessels can be 
well demonstrated. (Fig. 188.) 



CHAPTER V 

APPLICATION OF THE X-RAYS IN DISEASES OF THE 
ABDOMINAL ORGANS. 

I. Alimentary System. 

THE employment of the X-rays in the diagnosis of diseases of the 
alimentary system has not as yet yielded the same results or been as 
easy of application as is evidenced in diseases of the thoracic organs, 
for the obvious reason that there exist no tissue differences. 

There are various means of producing the necessary contrast or 
difference between these soft tissues : (1) by gaseoils distention, which 
renders the stomach more translucent ; (2) by the introduction of 
opaque instruments or mechanical methods ; (3) the bismuth subnitrate 
method, by which the organs become more opaque ; (4) the transillumi- 
nation method, which consists in illuminating the stomach by the intro- 
duction of fluorescent materials, radium, etc. 

A. (ESOPHAGUS. 

In order to examine this tubular muscular organ, for its position, 
direction, etc., we may introduce a rubber sound with a metal point, or a 
rubber tube filled with mercury or fine shot. 

The fluoroscopic examination should be made with the patient in the 
semi-recumbent or standing position, so as to prevent the superimpositiou 
of the shadows cast by the vertebrae, heart, aorta, etc. Allow the shadow 
to fall on a clear area and apply the fluoroscope obliquely over the right 
and left sides, and also in the right and left antero- lateral positions. 

Skiagraphic examinations should be made in the same positions 
as in the fluoroscopic method, but the posterior position is more com- 
fortable for the patieqt. 

Stricture of the (Esophagus. Constrictions of the oesophagus can be 
best ascertained by the introduction of a bougie with metallic ends, or 
by the use of a metallic sound, and viewing its passage in the above 
manner. 

Stenoses of the (Esophagus. Barba 1 reports two cases of oesophageal 
stenoses, in which he made radioscopic observations. The chief point 
brought out in his study is, that the ordinary methods of examination for 
stenosis of the oasophagus (the most important of which is the use of 
sounds) do not enable us to differentiate an organic stenosis of the canal 
from a narrowing occasioned by the pressure of tumors in the mediasti- 
num or by other causes of compression. The presence of these causes of 

1 Riforma Medica, December 23, 1905. 
331 




FIG. 188A. STRICTURE OF (ESOPHAGUS (right oblique position). First ascertain the location of 
the stricture and then use the compression diaphragm. In this position the rays pass and throw the 
shadow of the oesophagus between the heart and the spinal column. Injury or fracture of the ribs may 
be radiographed in the same manner. 




FIG. 188B. The compression diaphragm can be used for localized strictures of the resophagus. 




FIG. 188C. HEART AND AORTA (ventral view.) This position is most convenient in radiographing 
the apices of the lung, and for ascertaining the size of heart and ascending aorta. 




FIG. 188D. STRICTURES OF THE (ESOPHAGUS AND AORTA (antero-oblique view;. 



DISEASES OF THE ABDOMINAL ORGANS. 335 

compression in the mediastinum is very difficult to determine by physical 
examination, and only the Rdntgen rays enable us to make an accurate 
diagnosis. In the two cases reported, radioscopy showed that the ste- 
nosis, in each, was caused by the compression of tumors in the posterior 
mediastinum. In both cases, the radioscopic examination was aided by 
the passage of a sound filled with a concentrated solution of bismuth 
subnitrate, or else provided with a metallic stylet. 

Diverticulum. A diverticulum may often be diagnosed by the above 
method. The bougie or sound may not enter into the pouch, however, 
when it becomes necessary for the patient to drink bismuth suspended in 
water ; one to two parts to 100 parts of water. When possible, skiagraphs 
should be taken, as it requires but a few minutes and the operator does 
not endanger his hands. 

Tumors. Dr. Hugh Walsham * reports two cases of carcinoma of the 
cesophagus. He says that, " we must not expect so definite a shadow 
"as seen in cases of aortic aneurism." The diagnosis of an oesophageal 
growth is more difficult than that of aneurism. 

Before the screen examination he gives the patient two drams of 
carbonate of bismuth, suspended in a little milk or mucilage. This 
will map out the seat of the obstruction, whilst the topography of the 
ossophagus can be traced by a metallic bougie. 

B. STOMACH : SIZE, SHAPE, AND POSITION. 

Examination by Aid of Gaseous Distention. This method consists in 
distending the stomach by the ingestion of certain chemical agents 
which upon reaction result in the evolution of gases. The chemical 
most frequently employed is Seidlitz powder. Upon the fluoroscope the 
stomach appears as a dark area, upon the negative as a light area. This 
method causes the distention of the stomach walls and the displacement 
of the surrounding organs, so that little information can be gained by 
this procedure. 

Mechanical Method. In this method, a rubber tube containing a 
spirally coiled wire is introduced through the mouth into the stomach. 
Turck's gyromele is a device employed to determine the outline of the 
stomach by iluoroscopic means. 

Neumann * uses a Folitzer rubber bulb with a soft stomach tube for 
aspiration of the stomach contents. After the stomach has been emptied 
and a clean bulb attached to the tube, it is possible to determine the out- 
line of the stomach with great precision, by listening to the sound when 
air is forced from the rubber bulb into the stomach. A small amount of 
air is sufficient for the test, thus avoiding distention of the organ. 
In every instance radioscopy confirms the findings of auscultation as 

1 Archives of the Kontgen Ray, April, 1903, p. 114. 

2 Journal of the American Medical Association, July 23, 1904. 



336 ELECTRO-THERAPEUTICS. 

the bulb is compressed and the air forced into the stomach. This test 
is useful in dubious cases in the differentiation of gastric from intestinal 
stenosis. 

The Bismuth Subnitrate Method. This method consists of the inges- 
tion of subnitrate of bismuth, either mixed with food suspended in water, 
or administered in capsule form. This method was introduced and first 
employed by MM. J. Ch. Roux and Balthazard. 1 In 1897, F. Williams, 
of Boston, applied this method most extensively. The employment of 
the bismuth test, at the present time, is universal. 

Technic of the Bismuth Method. Chemically pure bismuth subnitrate 
should always be employed. Cases of poisoning, though not fatal, have 
been reported where the impure salt was taken. The stomach should be 
empty, no water should be partaken of, and the bowels should be 
thoroughly purged twenty-four hours prior to the examination. Roux 
and Balthazard use bismuth subnitrate in the proportion of 0.20 per cubic 
centimetre. Williams has administered as much as one ounce of bismuth 
emulsion. Hultz gives the patient the bismuth in a pint or more of 
milk. Boas advises the partaking of bread and milk or of potato soup, 
into which has been stirred one ounce, or more, of the bismuth salt. 

Fluoroscopic Examination. "y^illiams recommends examination of the 
patient with the fluoroscope, as ' ' the stomach moves during respiration, 
and therefore its outlines are blurred on the radiograph." 2 

Holzknecht and Brauner 3 assert that the passage of a bismuth tablet 
into the stomach can be traced and its expulsion watched, and that "the 
action of massage on the stomach, displacement of the organ during 
respiration, etc., can be better studied by a fluoroscopic examination." 

1 do not employ the fluoroscope, as it is dangerous alike for the 
operator and patient, and because the taking of a skiagraph is only a 
question of seconds. A severe X-ray dermatitis occurred in the hospital 
while the attending physician and my assistant were examining such a 
case with the fluoroscope. 

Skiagraphic Examination. The patient lies over a 14 x 17 inches 
(35 x 43 cm.) plate, a penny being placed over the umbilicus and then 
secured by adhesive plaster. The patient must remove his clothing. 
The ventral or dorsal decubitus, sitting, standing, or semi-recumbent 
position may be employed. 

In the ventral position, the anterior wall of the stomach comes in 
contact with the plate. In the dorsal position, the posterior wall will be 
nearer to the plate. In the sitting or standing position, the weight of 
the bismuth will depress the lower border of the stomach, so very impor- 
tant in the study of cases of gastroptosis. The ventral position is to be 

X C. R. de 1' Academic des Sciences, 1896. Bouchard, Traite de Radiologie Medi- 
cale, p. 995. 

2 Williams, The Rontgen Rays in Medicine and Surgery, p. 367. 
'Wiener klin. Rundschau, 1905, vol. xliv. p. 1971. 



DISEASES OF THE ABDOMIXAL ORGANS. 337 

preferred, because the bismuth adheres upon the anterior gastric wall, 
presenting clearly the fundus, the cardiac end, and the general contour 
of the organ. 

The Crookes tube should have a high vacuum. The anode is placed 
perpendicularly over the third and fourth lumbar vertebrae, at a distance 
of 20-25 inches (50-63 cm.) from the plate. 

Time of Exposure. The time of exposure should be as short as 
possible, because of the danger of blurring, occasioned by peristalsis and 
from the diaphragmatic movements. The exposure can be made suffi- 
ciently short either after a full inspiration or after a forced expiration. 
Narcotics to lessen peristalsis are seldom necessary. In corpulent 
subjects, especially when the apparatus is inadequate, the intensifying 
screen can be used ; but when a fine negative, full of detail, is to be 
brought out, the granularity produced by the screen is a serious disad- 
vantage. I employ a high-vacuum tube, with an electrolytic interrupter, 
duration 3 to 15 seconds, thus allowing the patient to hold his breath 
after a full inspiration. 

Dr. Henry K. Pancoast l reported the cases of 40 patients, suffering 
with gastric or gastro-intestinal symptoms. The technic he employs is as 
follows: "Bismuth subnitrate held in suspension in mucilage of acacia 
(proportion of two ounces of the powder to the pint) (or 64 grams to 
one-half litre) was either poured into the stomach through the stomach 
tube or was swallowed by the patient ; the latter method was principally 
used. The bulk of the bismuth-acacia mixture varied from six to 
thirty-two ounces (190 to 700 grams). Immediately after the bis- 
muth had reached the stomach the pictures were taken, the patient 
being in the standing position, and the plate in contact with the anterior 
abdominal wall. 

"The rays were thrown posteriorly, the patient holding the breath 
during full inspiration for an exposure of eight to fifteen seconds ; thus 
eliminating blurring by respiratory and peristaltic movements. After 
the picture has been taken, it is advisable to siphon the bismuth mixture 
out of the stomach. 

"In several cases as much as four ounces of bismuth was left in the 
stomach with no unpleasant symptoms ; but on the other hand, six cases 
showed toxic symptoms after this amount had not been removed. For 
the purpose of obtaining the lower border and segment of the stom- 
ach, six ounces of the emulsion containing one ounce (32 grams) of 
bismuth is sufficient. This amount has been left in the stomach with 
no bad effects." 

Dr. Joseph Sailer, of Philadelphia, has reported untoward symp- 
toms following the administration of bismuth. The symptoms varied, 
but cyanosis, dyspnoea, nausea, etc., were noted in several patients. The 

1 University of Pennsylvania Medical Bulletin, August, 1906. 
22 



338 ELECTRO-THERAPEUTICS. 

presence of antimony and arsenic was excluded, and it was thought that 
the rays had a peculiar action on the trypsin, with disintegration of the 
subnitrate. Undoubtedly the action only started after the bismuth had 
been for some period in the intestine, and had been acted upon by the 
ferments present. 1 

Dr. Henry Hultz 1 asserts that: ''Immediately after the bismuth 
meal two dorso-ventral exposures are to be made, one in the standing or 
sitting position, and one in the recumbent position. Assuming that the 
first Rontgenographs were taken at noon, the next one should be made 
about six hours later, the patient having partaken of neither fluids nor 
solids since the noon hour." 

He employs the following technic : A 16-inch coil, Wehnelt inter- 
rupter, but one intensifying screen, a strong tube yielding "Walter six 
rays, placed 20 inches (50 cm.) from the plate. He succeeded easily 
in skiagraphing the stomach of a medium-sized subject in one second, 
and obtained a very good plate taken under the same conditions but 
without the use of intensifying screens in three seconds. He prefers an 
exposure of ten seconds without the screen. 

Holzknecht and Brauner 3 recommend the following technic : The 
views are taken standing and reclining and during inspiration and expi- 
ration ; the most important information generally being obtained by radi- 
oscopy. To examine the standing patient, the Rontgen tube and the fluo- 
rescent screen are suspended by weights from a wooden standard, parallel 
to each other. The patient swallows a tablet of bismuth and, after its 
course has been traced, he drinks 50 grammes of water into which 10 
grammes of bismuth have been stirred. After the findings of this test 
have been noted, the patient is directed to drink a mixture of 4 grammes 
of tartaric acid and 5 grammes of sodium bicarbonate. On the following 
day, the patient is given 400 grammes of milk gruel containing 35 grammes 
of bismuth while he reclines on the left side, with the Rontgen tube applied 
to the dorsal aspect of the body ; subsequently he is examined when 
lying on the right side and again when in the dorsal posture. 

Hemmeter of Baltimore* has recently used the following method : 
"The dilated stomach is coated internally with bismuth subnitrate by 
means of a powder blower, after which its outline can be distinctly 
recognized through the fluoroscope." 

Rieder 5 says : "Let the patient swallow a mixture of 10 or 15 grammes 
of bismuth subnitrate suspended in 50 c.c. of water, and observe deglu- 
tition by the fluoroscope. The act of swallowing may be studied more 
leisurely if a small quantity of the bismuth salt be given in a pill. For 

1 University of Pennsylvania Medical Bulletin, August, 1906. 

7 Transactions of the American Rontgen Ray Society, 1906, p. 45. 

'Wiener klin. Rundschau, vol. xliv. p. 1971. 

4 Diseases of the Stomach, p. 640. 

'Miinchener med. Woch., epitome in Medical Record, Feb. 10, 1906. 



DISEASES OF THE ABDOMINAL ORGANS. 339 

more exact observation, a bismuth meal is employed. Thirty grammes 
of bismuth subnitrate are mixed with a little milk and this is then added 
to 300 or 400 grammes of flour gruel, sweetened with milk-sugar to 
obviate constipation." 

Dalton and Reid 1 obtain the position of the stomach by the employ- 
ment of an cesophageal tube containing bismuth. 

The Transillumination Method. This method consists in introducing 
some radio-active substances, or an electric light or air into the stom- 
ach, and then viewing the viscus with the lluoroscope or by taking a 
skiagraph. 

Max Einhorn 2 remarks that : " Transillumination into the stomach 
can be demonstrated with Kahlbauin's barium platino-cyanide, or by 
means of a photographic plate. The latter method has the advantage 
that no dark room is required and that the result obtained is visible to 
every one, leaving nothing for imagination or speculation. 

"In order to procure a radium photograph of the stomach I pro- 
ceed as follows : The patient should be in the fasting condition (empty 
stomach). The radio-diaphane, containing 0.05 gm. (or more) of pure 
radium bromide, is introduced into the stomach. The patient occupies 
a recumbent position, and a photographic plate is put directly over the 
gastric region and allowed to remain there for one or two hours, accord- 
ing to the requirement of the case. The plate is then removed and the 
radio-diaphane withdrawn. The plate is then developed. 

"Contrary to my expectations, radium enclosed in a quartz flask 
failed utterly to transmit the photographic rays, while thin ordinary 
glass answered the purpose very well. 

"The shortest time for obtaining a photographic outline of the 
stomach is one hour ; in less than an hour hardly anything is visible ; one 
and a half to two hours bring out the outlines more distinctly. Insuffla- 
tion of air into the stomach occasionally aids in obtaining a good picture. 

"A few of the better radium photographs in my possession are 
reproduced herewith and show that transillumiuation of the stomach by 
means of radium is feasible. It is even possible to recognize an area of 
light which had to pass through the posterior wall of the stomach and 
the back of the thorax. One of my negatives shows a key which was 
hanging below the left scapula and was thus photographed by the trans- 
mitted light from the stomach. 

"Considerable sized tumors of the stomach or liver can, sometimes, be 
recognized on the picture by the diminished translucency. Thus far, how- 
ever, I have not succeeded in obtaining definite outlines of the growth." 

Sinclair Tousey 3 finds the radio-active and fluorescent solutions, as 

1 Lancet, April 1, 1905. 

2 Archives of Physiological Therapy, Sept. 1905, p. 115. 

3 New York Medical Journal, May 21, 1904. 



340 ELECTEO-THERAPEUTICS. 

prepared by him with quinine bisulphate and fluorescin, are innocuous 
when given by the mouth or subcutaneously, but do not produce singly, 
or in combination, sufficient fluorescence to be of value in the examina- 
tion of the stomach without the use of some additional light to excite 
their fluorescence. In some cases, however, they will be of the greatest 
assistance in the diagnosis of stomach lesions, and at times of advantage 
in X-ray treatment. 

In cases of gastroptosis, I have had experience with this method at 
the Philadelphia Hospital, where it has not afforded me any satisfaction. 

C. THE CLINICAL APPLICATION OF THE BAYS. 

Stomach. The behavior of the stomach during digestion has been 
studied with the X-rays on cats and dogs by W. B. Cannon. 1 The out- 
line of the stomach was reproduced on the screen by giving the animal 
small, but frequently repeated doses of bismuth subnitrate. After a 
plentiful feeding the viscus was observed to be considerably larger, 
gradually diminishing in size as the process of digestion proceeded ; at 
the same time, the cardiac end acted as a reservoir for the ingested food 
while the pyloric region presented marked peristaltic movements. It was 
further noted that liquids soon pass from the stomach, while solids remain 
there for an indefinitely longer period. 

The activity of the digestive juices can be determined by giving the 
patient a small quantity of bismuth in a small capsule of gold-beater's 
skin or gelatine. As the patient swallows, the shadow of the opaque 
spot is demonstrable on the fluorescent screen so long as the capsule is 
intact. When the gold-beater's skin has been disintegrated by the action 
of the digestive juices, the particles of bismuth become diffused and 
the black spot is no longer seen on the photographic plate or screen. 
The time occupied by the digestion of the capsule is a measure of the 
activity of the stomach and the quality of the peptic juices. 

Repeated examinations will reveal the time that is required to empty 
the contents of the stomach. The bismuth accumulates near the py- 
loric end and passes to the intestines. This consumes a period of about 
6 or 7 hours. 

Position of the Stomach. Butler 2 asserts that : " The lower border of 
a normal but much distended stomach may be found at the level of the 
navel. If below the umbilicus the condition is abnormal." Quaiu believes 
that : " It is generally a little (half an inch to an inch) above the highest 
point of the iliac crest, and about opposite the disk between the third 
and fourth lumbar vertebrae." 3 The shadows of the normal stomach 
being approximately known, any increase'or decrease in the interval from 

'American Journal of Physiology, vol. i., May 1, 1898. 
*" Diagnostics of Internal Medicine," p. 543. 
8 Quain's Anatomy, vol. i., p. 679. 



DISEASES OF THE ABDOMINAL ORGANS. 341 

the umbilicus will inform the skiagrapher of any abnormal gastric posi- 
tion. When the tube is at a distance of 20 inches (50 cm.) the distortion 
will be very small. 

Holzknecht, 1 however, believes that : " A stomach which is of nor- 
mal size and situated in the normal position is rarely visible ; but when 
gastroptosis occurs the stomach becomes visible. When the walls of the 
stomach are infiltrated with carcinomatous deposits, abnormalities in the 
contractions of the organ are readily observed, when food mixed with 
bismuth is given to the patient." 

Rieder had large quantities of bismuth mixed with the food and 
given in enernata, and then examined the patients with the screen. His 
deductions are contrary to the teachings of text-books. "When the stom- 
ach is full, the pylorus, for instance, may be found to the left of the 
median line. The full stomach lies vertical or diagonal, never horizontal. 
There is always an accumulation of gas to be noted in the upper part of 
the fundus during stomachic digestion. He also observed interesting 
facts concerning the motor functions of the stomach and of the various 
parts of the intestines. 

Gastroptosis. This condition is best shown skiagraphically (Fig. 189) 
while the patient is sitting or standing, or in both dorsal and ventral 
positions ; otherwise the condition may not be detected. Often there 
will be a difference in the position of the stomach depending upon 
whether the skiagraph is made after full inspiration or after full 
expiration. 

The form, size, and shape of the stomach can be ascertained by a 
careful study of the normal stomach and then by comparing it with 
any supposed abnormality, being careful that the technic is identical in 
each case. 

G. Leven and G. Barret 2 studied the outlines of the stomach by 
following the path of a bismuth pill, and came to the conclusion that : 
" Our ideas of the shape of the stomach in life demand revision, also that 
the lower curve of the organ does not sweep across the abdomen, but that 
the cardiac end has a small amplitude from which the line runs inward, 
then sharply down to, or below the umbilicus, and as sharply up again 
towards the pylorus. 

11 The form of the stomach has therefore not the regular lines hitherto 
drawn, and such as we see after death ; but the superior part is dimin- 
ished in size by the dilatation of a tube-like process going downward 
from the lower border towards the navel." 

The authors aver that in the normal stomach this tubular part re- 
ceives fluids till it is full. When more liquid is added, the tube begins 
to expand, so that the level of the liquid remains constant for a time, 
when the latter finally invades the rest of the cavity of the stomach. On 

1 Berliner klin. Wochen., February 28, 1906. 

2 Presse Medicale, Paris, January 31, 1906. 



342 ELECTRO-THEKAPEUTICS. 

the other hand, in a dilated stomach the authors' characteristic method 
of filling is not evident ; the fluid collects in the lower curve of the 
viscus, and the level rises slowly and regularly. 

Stenosis of the Pyloric End. When the average time which is neces- 
sary for the passage of the food (bismuth) for a normal stomach is pro- 
longed (over G hours), it is indicative of stenosis of the pyloric end, or 
of gastric insufficiency, either caused by dilatation or atony. The ski- 
agrapher should make several exposures to determine the time required 
to empty the stomach. 

D. INTESTINES. 

If only the stomach is to be examined, the bismuth can be pumped 
from the stomach after the skiagraphs are made ; if allowed to remain 
for three, six, or eight hours, the bismuth passes into the intestinal canal 
in 15 or 20 hours. It is possible to obtain skiagrams of the colon and 
other portions of the intestinal tract. 

Eieder 1 declares that: "For the large intestines, rectal injections 
may be used ; and that by the use of one litre of fluid containing bismuth 
it is possible to insure penetration as far as the ileo-caecal valve." 

Sounding and Radiography of the Large Intestine. Schiile 2 has been 
testing various sounds, including Kuhn's flexible spiral sounds and also 
the Kassel soft tubes with flexible metal guide, terminating in a button 
2i to 31 inches (5.5 to 8 cm.) in circumference, thus obviating all danger 
of perforating the intestinal wall. His conclusion is, that no convincing 
proof has been obtained, to date, that a sound has been successfully 
passed into the descending colon, to say nothing of the transverse portion. 
The innumerable folds, windings, and swellings of the intestine render 
it impossible to determine whether an obstacle to the progress of the 
sound is of a natural or a pathological nature. On the other hand, the 
direct visual inspection of the rectum and the sigmoid flexure by the 
J. Schreiber and H. Strauss technic is perfectly reliable. Schiile found 
that "high injections" were practicable, the best vehicle being oil. An 
injection in the knee-elbow position of 300 to 400 c. c. of oil with 125 
gm. of bismuth subnitrate, followed by radiography, showed that the oil 
had penetrated to the ileo-csecal valve. In two of the patients there was 
pronounced enteroptosis, the transverse colon in one hanging suspended 
like a garland from the two points of attachment at each end, the centre 
reaching far below the upper plane of the pelvis. On account of the 
small amount of the oil injected, and the fact that the subject was in the 
knee-elbow position at the time, the injection could not have been 
responsible for the sinking of the intestine. The radiograms show per- 
fectly the topography of the colon for its entire extent. They also prove 

'Munch, med. \Voch.. epitome in Medical Record, February 10, 1906. 
2 Archiv f. Verdauungs-Krankheiten, Berlin, last indexed page 863. 



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DISEASES OF THE ABDOMINAL ORGANS. 34.5 

that the ileo-caecal valve is always continent. Tests on the cadaver 
showed that extreme pressure, beyond what would be possible in the liv- 
ing subject, is necessary to force it open. 

Intestinal Obstruction. Rudis-Jicinsky l reports two such cases : one, 
a boy of 10, swallowed a tin whistle, and the usual symptoms of intestinal 
obstruction followed. The site of the occlusion could not be determined 
in the usual way. On X-ray examination, the whistle was found at the 
junction of the small and large intestine. On the third day the whistle 
was passed. A boy, of 12, had symptoms of obstruction and was in a 
serious condition. The first diagnosis was one of invagination at the 
lower portion of the ileum. On X-ray examination an obstruction was 
found in the small intestine under the umbilicus. Laparotomy was 
performed, and the obstruction was discovered to be caused by a small 
wooden whistle. The author has produced artificial obstruction in dogs, 
and then traced a specially prepared pill to the point of obstruction by 
means of the X-rays. The diagnosis in such cases was verified. 

I believe that the exact location of the obstruction or of a particular 
portion of the intestine cannot be determined because of the superimposi- 
tion of the coils of the intestines ; but an approximate location in the 
abdominal cavity can be ascertained by the direction of the passage 
traversed by a specially prepared opaque pill. 

An important case coming under my care was that of a man, 42 years 
old, suffering with symptoms of intestinal obstruction. An X-ray exami- 
nation was conducted, revealing a large-sized enterolith. The seat of 
obstruction was at the ileo caecal valve. An operation was performed and 
the obstructing mass removed. Three years prior to this, the patient had 
been a sufferer from biliary calculi, but refused to undergo an operation 
at that time. It is very likely that this intestinal calculus was primarily 
a biliary calculus which passed into the intestines and there remained 
for a period of three years, gradually becoming larger and larger. The 
exterior of this stone was uniformly softened, while the centre was ex- 
tremely dense. 

Following a biliary colic, it is always advisable to ascertain, by an 
X-ray examination, if calculi have been passed into the intestinal tract. 

Rectal Imperf oration. The following case is illustrative of this con- 
dition. A child when born was observed to have an imperforate anus, 
with an absence of rectal tract. A consulting surgeon suggested an 
inguinal colostomy. The child lived with this annoying condition for 
twelve years. It was then decided to try further surgical means. I 
proceeded to examine the case, as follows : Into the rectum through the 
artificial anus, I injected an emulsion of bismuth subnitrate, at the same 
time passing a steel sound through the anus to the point of obstruction 
at the lower end of the rectum. A skiagram proved the obstruction to 

1 Medical News, Oct. 5, 1901. 



344 ELECTEO-THEEAPEUTICS. 

be two inches in length. The upper part of the rectum was anastomosed 
to the ileum, after first removing the coccyx. For ten subsequent days 
the faecal material passed through the newly constructed channel. 1 

Abdominal New GrowtJis. The recognition of neoplasms located in 
the abdominal cavity, by means of the X-rays, is a rather difficult task. If 
the tumor is dense, it may cast a shadow upon the screen : if more or less 
soft, no shadow will be cast. These pathological masses are frequently 
recognized by their effects upon adjacent structures, as in a displacement 
of the diaphragm, liver, etc. I have made numerous examinations of 
suspected carcinomata of the stomach, some of the results being favor- 
able, though the vast majority proved unsatisfactory. It must not be 
forgotten that in carcinomata of the pylorus there is some interference 
with the movement of the diaphragm on that side, the latter not de- 
scending to so low a point as in the normal. 

E. LIVER. 

The correct general outline of the liver may be obtained by combin- 
ing a fluoroscopical and physical examination. The upper or convex 
border of this organ can very readily be ascertained by the fluorescent 
screen, while the lower and concave border is best outlined by palpation 
and percussion. Echinococcus cysts, when located in the immediate 
vicinity of the upper border, may be easily diagnosticated by this means. 
When examining this organ, it is always advisable to have the adjacent 
portion of the stomach and intestines filled with air or gas, so as to more 
readily define the lower border of the liver. A skiagraphic examina- 
tion, especially in adult cases, is very unsatisfactory. In young children 
better results are obtained. 

Biliary Calculi. The results of a skiagraphic examination in this 
condition depend to a very large extent upon the chemical composition 
of the calculus. Upon the negative, only a very light shadow of the 
stone is thrown and can, by a very careful examination, be seen only 
with difficulty, even though it is of rather large size. Occasionally large 
calculi can even be detected in the heptic duct. Calculi composed of 
bilirubin and certain other substances are not very permeable to the rays. 
Those calculi consisting of cholesterin, being largely composed of calcium 
salts, show more distinctly on the negative than do the others. Early 
experiments upon gall-stones have been reported by Neisser, Goodspeed, 
and Cattell.' 

A fluoroscopic examination for biliary calculi is thoroughly unsatis- 
factory, and until a skiagram is taken no absolute diagnosis should be 
rendered. The method I employ is as follows : The patient rests upon 
the table (upon his back) with the head-end raised and the foot-end 

1 For full report of this case see Hemmeter, " Diseases of the Intestines," vol. ii. 
1 Medical News, Feb. 15, 1896. 




FIG. 189A. STOMACH AND INTESTINES. The patient stands in the opening of the table against its 
upright portion. Plate 14 in. x 17 in. (35x43 cm.) Kidneys (floating), spleen and diaphragm may 
also be thus radiographed. 




FIG. 189B. LIVER (ventral view. ) Patient lies on a plate 10 in. x 12 in. (25 x 30 cm.) which is 
placed on a wedge-shaped block of wood. 



DISEASES OF THE ABDOMINAL ORGANS. 345 

depressed, the whole top of the table slanting in a position of 45. The 
abdomen should be bared of clothing and lightly bandaged, in order to 
lessen the peristaltic and respiratory movements. The patient is slightly 
turned toward the right side. A sensitive plate of proper dimensions is 
firmly fixed by a clamp and bracket to a stand in front of the affected 
region. A tube of the highest penetrative power is placed under the 
table, with the target pointing in the direction of the gall-bladder, or the 
patient may be placed in the ventral position with the tube above. The 
shoulders should be elevated, so as to bring the shadow of the gall- 
bladder outside of the shadow of the lower lobe of the liver. The time 
of exposure varies, depending upon the thickness of the part to be 
traversed by the rays. 

The presence of calculi is very difficult to detect, because their 
chemical composition allows the passage of the rays, they being largely 
composed of the hydrocarbon cholesterin. Moreover, the shadow of the 
calculus is very liable to be obscured by the shadow of the contents of the 
gall-bladder. When the stone finds its way into the intestine and there 
becomes coated with calcium phosphate and carbonate, the shadow cast 
will be more definite, as the latter salts offer a resistance to the passage of 
the rays. 

Dr. C. Thurston Holland J reports the following case: "A woman, 
of 45, had two attacks of severe abdominal pain, one accompanied by 
slight jaundice. A tumor was discovered in the right abdomen and 
diagnosed as a distended gall-bladder. 

" The radiograph was taken with a 12-inch coil and a mercury break. 
Current employed was 24 volts and 10 amperes. A Cox regulator tube 
was used with a spark-gap of 3 inches (7.5 cm.) and through a pressure- 
tube apparatus designed by the author. An exposure of two minutes 
was given. The stones, each three-quarters inch (2 cm.) long, were 
lying end to end, from before backward, and cast annular shadows with 
the patient lying with the abdomen downward on the plate. A second 
radiograph, taken with the woman on her back, also showed the same an- 
nular shadow, but, the stones being further from the plate, the shadow 
was larger and not so well defined. A surgical operation disclosed two 
stones of the usual type ; one weighed 100 grains (6.4 grams), the other 
113 grains (7 grams), which were composed of concentric laminae of bile- 
pigment and cholesteriu. Calcium was present, but greater in quantity 
at the periphery, where the stones were much harder. 

"The success attained in this case was due to the presence of lime- 
salts, and to the employment of a pressure-tube apparatus which fixed the 
part and cut off all except a small central stream of X-rays, and most of 
the secondary rays, and thus prevented fogging of the plate and blurring 
of the shadows." 

1 Archives of the Rontgen Ray, Feb. 1906, p. 241. 



346 ELECTRO-THERAPEUTICS. 

Dr. Carl Beck ' made 97 skiagraphs of 28 suspected cases of cholelithi- 
asis ; in 19 of those cases the presence of biliary calculi was ascertained 
by operation. In only two of these 19 cases was he able to obtain 
shadows on the plates. Later, had good skiagraphs of gall-stones ex- 
hibited at a meeting of the Academy of New York, held in January, 1901. 

For cutting off' the secondary rays I think the compression dia- 
phragm is at times useful. I have had cases where the plates showed 
shadows of the distended gall-bladder, but not of the calculi, because 
fluid offers great resistance to the passage of the rays. In most instances 
the shadow will be too low when the calculi have passed into the intestine. 

Recently, at the Philadelphia Hospital, I was asked to take a skia- 
graph of a very emaciated patient. I found the shadows of two renal 
calculi in the left kidney, and a round, small stone under the twelfth rib, 
on the right side, and a large one in the pelvis of the right kidney. The 
latter was subsequently removed, but the former defied surgical detection ; 
although I am sure the round shadow was that of a biliary calculus. 

I do not think the fluoroscope is as reliable in these cases as is the 
skiagraph, provided that in the latter the time of exposure is correct 
and the subject is a suitable one. I never have had a case of this kind 
where the diagnosis was solely made by the aid of X-rays and confirmed 
by operation. 

F. PANCREAS. 

On account of its peculiar anatomical situation, this organ cannot be 
easily recognized by an X-ray examination. In one instance I was able 
to obtain a shadow of this organ on a skiagram. The patient was unusu- 
ally emaciated, and from the clinical signs and symptoms, a diagnosis of 
carcinoma of the pancreas had been made. The patient was prepared as 
usual, and subjected first to a fluoroscopic and then to a skiagraphic 
examination ; a very faint shadow was discoverable, superimposed upon 
the one produced by the stomach. Since then, I have at frequent inter- 
vals tried to make similar examinations on different subjects, but have 
never succeeded in repeating or reproducing what then was considered a 
rather satisfactory image of this organ. In this instance I distended the 
stomach with air in order to allow as clear a field for this organ as possi- 
ble. I am of the opinion that this fairly good result was due to a peculiar 
abnormal principle which is opaque to the rays, and whose nature thus 
far has not been determined. 

G. SPLEEN. 

This organ is easily shown in children by means of the fluorescent 
screen. In adults the skiagraph only is satisfactory. The patient is best 
examined in the recumbent position, being slightly turned toward the left 

'New York Medical Journal, January 20, 1900. 



DISEASES OP THE ABDOMINAL OKGANS. 347 

side. The sensitive plate is placed in front of the patient in the region of 
this organ, with the tube below or behind. In those who are corpulent, 
it is best to place the patient in the prone position with the plate beneath 
and the tube above. 

Just prior to the examination, the large intestine should be distended 
with air. This procedure will serve to displace all of the adjacent organs, 
and at the same time permit the production of contrast between the 
lower edge of the spleen and the neighboring light area produced by 
these distended organs. The upper border is in relation with the 
diaphragm, and, in order to avoid the blurring of the image, the 
rays should be permitted to emanate from the tube only during inter- 
vals when the patient has ceased breathing. The screen examination 
of the spleen in a child demonstrates the fact that the anterior border 
moves slightly more than the posterior, as though this organ were turning 
on its long axis. 

II. Genito-Urinary System. 

The great strides made in surgery and surgical bacteriology within 
the past twenty years have effected a complete change in the conceptions, 
the prognoses, and the treatment of many surgical affections. Neverthe- 
less, prior to Bontgen's discovery positive diagnoses of many diseased 
conditions were manifestly impossible. The truth of this statement gains 
added support in the genito-uriuary field. Many of the pathological 
states of the kidney could be ascertained only by cutting down upon 
that organ, especially in suspected cases of calculi, displaced kidney, 
hydronephrosis, pyonephrosis, etc., frequently forcing upon the surgeon 
the serious embarrassment of operating upon some distant organ, wherein 
pain was experienced by the patient, the result of reflex irritation. In 
the same manner invaluable assistance has been lent by this new aid in 
the diagnoses, in many of the more obscure diseases and affections of 
the ureters, the bladder, and the prostate gland. 

The shadows of the kidneys are most difficult to show on the negative. 
The upper portion of the right kidney presents an added obstacle in the 
superimposed shadow cast by the liver. The affection of the kidney 
most frequently brought to the attention of the skiagrapher is that of 
suspected calculus. 

A. ORDINARY METHODS. 

It is common experience that a case of renal calculus will be evi- 
denced by a few of the classical signs and symptoms which not infre- 
quently confuse the mind of the diagnostician. Thus, Henry Morris, 
the eminent English surgeon, found renal calculi in two-thirds of his 
suspected cases. Brewer 1 mentions two instances where distinguished 

Annals of Surgery, May, 1901. 



348 ELECTKO-THERAPEUTICS. 

surgeons diagnosed stone in the kidney as cases of appendicitis. 
Bevan and Franks made the same error, the former suspected a case of 
appendicitis, and the latter ovarian disease. Jacobson 1 mentions at 
length the differential diagnosis between incipient spinal caries and 
renal calculi. 

Prior to the discovery of the X-rays, the most advanced studies in 
kidney affections were due to ureteral catheterization, introduced by 
Howard A. Kelly, of Baltimore, and to Harris's invention of the segre- 
gator, for drawing off separate urines from each kidney. The chief clini- 
cal aids may be stated as follows : 

General symptoms, chemical, macroscopic, and microscopic examina- 
tions of the urine with the addition of the centrifuge, percussion over the 
affected side, the ureteral catheter and sound, inspection of the bladder 
and ureteral orifices, and the segregator. With the possible exception of 
the actual finding of a stone in the urine, we are not absolutely convinced 
whether we are to deal with a nephritic calculus, if there is one or many, 
if it is in the ureter, or if one calculus is in the ureter and another in 
the kidney. If upon exploration only one stone is found, it is not 
conclusive evidence that others are not present, either in the ureter or 
some other part of the kidney. 

B. PENETRABILITY OF CALCULI. 

The most useful and accurate method thus far advanced for the 
detection of renal calculi is by means of the X-rays. Chapius and 
Chauvel, 2 in Paris, were the first investigators to study renal calculi 
by the aid of the X-rays. They mention that calculi, whose chemical 
structure is uric acid, urates, or phosphates, cast shadows slightly less 
opaque to the rays than do compact bones. As the kidney substance 
is not so easily penetrated by the rays as muscular tissue, it would 
be natural to infer that the negative would show a lighter shadow than 
the adjacent tissue which is more penetrable by the rays. Dr. Mac- 
intyre, 3 of Glasgow, also made early and successful investigations on 
renal calculi. 

Dr. James Swain,* of Bristol, was the first to detect the different 
degrees of penetrability of different calculi. His method of investi- 
gation was as follows : On a sensitive plate he placed different calculi 
of the same dimensions, exposing them for periods of one, two, four, 
eight, and sixteen minutes. He early observed that "the more dense 
the object the deeper was the resulting shadow," and that the law first 
laid down by Eontgen was not true of different calculi. If tabulated 

1 British Medical Journal, January, 1900. 

2 Academic de Medecine, 21, iv., 1896. 
'Lancet, July 11,1896. 

4 Bristol Medico-Chirurgical Journal, March, 1897. 



DISEASES OF THE ABDOMINAL ORGANS. 349 

in the order of their highest specific gravity, their greatest permeability 
to the rays, and their greatest density of shadow, the results attained are 
as follows : 

SPECIFIC GRAVITY. PERMEABILITY TO THE RAYS. DENSITY OP SHADOW. 

1. Oxalate of calcium. 1. Biliary. 1. Oxalate of calcium. 

2. Uric acid. 2. Uric acid. 2. Phosphatic. 

3. Phosphatic. 3. Phosphatic. 3. Uric acid. 

4. Biliary. 4. Calcium Oxalate. 4. Biliary. 

* 

Dr. Swain exposed one calculus of each type with a section of rib 
and a piece of kidney. An increased time of exposure produced a 
fainter shadow, so that at the end of the "sixteenth minute," the calcium 
oxalate and phosphatic calculi, with a faint trace of rib, showed on the 
negative. The conclusions reached from these experiments are that the 
shorter exposures are better than long exposures, also that calcium 
oxalate and the phosphatic calculi show most plainly. 

If the exposures are too prolonged, the less dense calculi will pro- 
duce no shadow. Likewise a calculus of uric acid gives a fainter shadow 
than the rib, and in an eight minute exposure much less of a shadow than 
that of a rib covered partially with kidney. Thus we conclude that a 
calculus of uric acid is difficult of detection. 

The most accurate method is that advanced by Rontgen. The many 
errors made in the diagnosis or elimination of renal calculi were all due 
to a faulty technic, to an incorrect development of the plate, or to an 
erroneous interpretation of the negative. It is imperative to produce a 
skiagram that has detailed shadows of tissues less opaque than the least 
opaque calculus. 

By means of the X-rays we are enabled to diagnose hypertrophy, 
atrophy, displacement, tumors, hydronephrosis, pyonephrosis, and peri- 
nephritic abscess. Hypertrophy is a condition which is always unilateral, 
and, by comparison with the kidney of the opposite side, is readily diag- 
nosticated. The above mentioned conditions, however, can only be 
demonstrated in those subjects not too corpulent, when the exposure has 
been sufficiently long, and when the exposed negative has been properly 
produced by the developing process. The margin of the hypertrophied 
kidney is clear and sharp. If this sharp margin is irregular in any of 
its part, the examiner has found a neoplasm springing from the cortical 
area. Atrophy of the kidney is more difficult of diagnosis. The most 
usual cause is the existence of a calculus. 

Displacement of the kidney is a common affection, its occurrence 
being indicated by a knowledge of its normal relations and by a com- 
parison with the shadow produced by the abnormal position. Perine- 
phritic abscess can also be diagnosticated by the rays. The conditions 
favorable for best results are found in patients of slight build, and when 
the intestinal canal has been thoroughly evacuated. 



350 ELECTKO-TH ER APEUTICS. 

In hydronephrosis and pyoneplirosis, a shadow showing involvement 
of the pelvis of the kidney may be observed. This condition is more 
readily diagnosticated from a good negative than is a perinephritic 
abscess. 

Cases of gonorrhoea, with pus in the region of the kidney, have been 
diagnosed with the X-rays ; the skiagram showing an irregular mass on 
the convex border of the shadow produced by the kidney, the shadow 
of which is denser than that obtained from the normal kidney itself. 

C. TECHNIC OF RENAL SKIAGRAPHY. 

When renal calculi cannot be diagnosticated by skiagraphy, the 
chief causes will be found to be under- or over-exposure and improper 
development of the exposed plate, or because the tube lacks the necessary 
high penetrative power. 

Preparation of Patient. In taking a skiagram see that the patient is 
briskly purged, and that he abstains from all food for at least 24 hours 
prior to the time of exposure ; in the interval, give him a high enema. 
The bladder should be emptied just before the time of taking the 
picture ; if this be impossible he should be catheterized. The patient is 
placed in the recumbent posture, and the knees flexed, so that the normal 
lumbar curve will come in closer contact with the plate. Two plates of 
sufficient size to include both kidneys should be placed on top of one 
another, and protected by a celluloid cover, in order to prevent injury 
from excretions. The upper edge of the plate should correspond to the 
position of the tenth rib, and the lower edge to the superior part of the 
sacrum. This will include part of the ureters at the lower end of the 
plate. The tube should be of the highest penetrative power, so as to 
lessen the time of exposure. When both kidneys are to be skiagraphed 
the tube should be placed in the median line above the patient, and at 
a level corresponding to the position of the pelvis of the kidney. 

If only one kidney is to be skiagraphed, use a smaller plate, placing 
the tube in front of the patient, with the target pointing to the centre of 
the kidney. As respiratory movements interfere with the production of 
an accurate skiagram, the whole abdomen should be bandaged as tightly 
as possible. Some examiners prefer the patient holding his breath 
during exposure, but I have encountered some difficulties in attempting 
to carry out this method. For skiagraphing the renal organs,! always 
use the Wehnelt interrupter. 

C. C. Slaberia and A. P. Slaberia, 1 of Barcelona, recommend the use 
of a moderately hard tube (except in cases of very stout patients, when 
a hard tube should be employed) and a long exposure, varying from three 
to six minutes in children, as much as thirty minutes in adults, and up 
to sixty-five minutes in very stout persons. They do not employ an 

1 Fortechritte a. d. Get), der Rontgenstrahlen, Band v., Hefte 2, 3. 



DISEASES OP THE ABDOMINAL ORGANS. 351 

electrolytic break, nor have they seen any erythema or other injurious 
effects, although in one instance the patient was skiagraphed seven times. 
Except in the case of a displaced or very movable kidney, they advise 
the dorsal position of the patient. Despite some advantages, they con- 
sider the ventral position inadvisable because of the increased distance 
of the kidney from the plate. Dr. Charles L. Leonard, of this city, was 
the first to advocate a low- vacuum tube, with a spark-gap of U to 2 inches, 
(4-5 cm.) which is self regulating, and which will give a large volume of 
low-vacuum Rontgen discharge. He formulates this axiom, " that in a 
negative possessing a differentiation in the shadow of tissues less dense 
than the least dense calculus, no calculus can escape detection." Per- 
sonally I agree with Shenton and those other skiagraphers who advocate 
the high- vacuum tube with a short exposure. The latter is advantageous 
in taking negatives of suspected calculi, for these can be applied while 
the patient " holds his breath," thus avoiding diaphragmatic movements. 
I always make several short exposures when skiagraphing this region. I 
believe there is less likelihood of penetrating the calculus with the high 
tube and short exposure, than with a softer tube and a longer exposure. 
I cannot advise the use of the intensifying screen, because of the gran- 
ularity presented on the negative ; neither do I recommend the compres- 
sion diaphragm, as we do not know where to apply the latter, as it covers 
only a small area at a time, and thus prevents comparison between the 
abnormal and the corresponding normal part. Dr. Joseph F. Smith, in 
his paper "The Rontgen Ray Diagnosis of Renal Calculus," 1 remarks : 

"In 1899, Abbe collected from literature and tabulated twenty-five 
cases in which a positive diagnosis had been made by the X-ray and later 
confirmed by operation. To this list of twenty-five he added two cases 
of his own, making twenty-seven cases reported up to that time. These 
twenty-seven cases are arranged by years as follows : 1896. Macintyre, 
of Glasgow, reported the first skiagraph of a stone taken in the body. 
Swain, of Bristol, reported a case. 1897. Gurl, Nuremberg ; Fenwick, 
England ; Thyne, Australia. 1898. Bevan, Chicago ; McArthur, Chicago ; 
Lauenstein, Germany ; Alsburg, Germany ; Martin, England ; Taylor, 
England ; Fenwick, England ; Leonard, Philadelphia, eight cases ; 
McBurney, New York ; Abbe, New York, two cases. 1899. Wagner, 
Germany, two cases." 

Speaking upon the probable errors likely to arise in cases of ne- 
phritic calculi, Dr. Chas. L. Leonard, one of the greatest authorities on this 
subject in America, says: 2 " The absolute negative and positive diagnosis 
of calculous nephritis and ureteritis can be made with an error of less 
than 3 per cent. A statistical study of the 320 cases examined shows 
that calculi have been found in 93 cases, or a little less than a third 
of the cases examined. In many of the cases, in which a negative or 

1 Annals of Surgery, May, 1904. 2 American Medicine, June 4, 1904. 



352 ELECTRO-THERAPEUTICS. 

exclusion diagnosis was rendered, the patients had such slight symptoms 
as to render the presence of calculi possible, but not probable. In 47 
cases the symptoms demanded operative intervention, and in all but one 
the accuracy of a negative diagnosis was proved by the operation, and no 
calculi were found. In many of the cases of negative diagnosis in which 
there was no operation, the subsequent development of other conditions 
showed that the diagnosis had been correct. In three cases of negative 
diagnosis, small calculi, that had escaped detection, were subsequently 
passed. Thus, there has been a total error of but four cases in the 
negative diagnoses, one due to defective technic, and the others to 
inaccurate reading of the plates." 

Bevan 1 published a paper in the Annals of Surgery, reporting 13 or 
14 cases, and claimed that the X-ray as a means of diagnosis w r as to be 
relied on to a greater extent in cases of kidney stone than any other means 
at our disposal. He thinks the best exposition of this entire work is to 
be found in "Beitriige fur Chirurgie," from the pens of Kuminel and 
Rumpel. Kummel takes the position of Leonard and Bevan, and pre- 
sents practically these conclusions, that the X-ray, properly used, will 
detect a stone in any individual, no matter how thick, or of what chemical 
composition ; that the detection of the stone does not depend so much on 
its chemical composition or the thickness of the individual, as it does on 
the proper use of the X-rays. 

Kummel and Rumpel 2 report a series of eighteen cases diagnosed 
positively by the X-rays, all of which were subsequently operated 
upon, and stone extracted. The conclusions drawn from their work are 
as follows : 

"The exact diagnosis of kidney stone is to be made only by means 
of the Rontgen procedure. 

"The presence of a kidney stone, whether located in the kidney 
substance, the calices, or in the ureter, will be demonstrated upon the 
plate in every case, by proper application of the Rontgen method. 

"The negative result of the Rontgeu method after repeated attempts 
allows of the exclusion of a calculus. 

"The demonstration of a stone shadow upon the Rontgen plate is 
not dependent upon the size and chemical composition of the calculus, 
but singly and alone upon the technic of the Rontgen operator. 

"A high degree of corpulence in the patient may render the demon- 
stration of a calculus by the Rontgen method very difficult, but in general 
does not render it impossible. 

"In every case of nephrolithiasis it is advisable to employ the 
functional methods of investigation, since they show us by combined 
application (a) whether a disturbance of the whole kidney function exists 

Journal of the American Medical Association, March, 1905, p. 1062. 
2 Beitriige fur klin. Chirurg., 1903, Band xxxvii., Heft 2. 




FIG. 189C. KIDNEY (dorsal view.) Patient flexes his knees. Plate 8 in. x 10 in. (20 x 25 cm.) 
extending from the eleventh dorsal rib to the flank. 




FIG. 189D. V ESI as; (dorsal view.) Patient sits in the semi-recumbent position. Plate 10 in. x 12 
in. (25 x JX) cm.) . 



DISEASES OF THE ABDOMINAL ORGANS. 353 

or not, (&) whether we have to deal with a double-sided stone formation 
or other coexisting kidney disorder, or whether in the already existing 
disorder only one kidney is involved. 

"The result of the negative Rontgen investigation should be consid- 
ered in connection with the condition of the clearness, concentration, and 
freezing-point of the urine obtained by means of the ureteral catheter." 

In the eighteen cases tabulated by Rumpel. two of the stones removed 
contained only triple phosphates. All the others consisted of mixtures 
in different proportions of calcium carbonate, calcium phosphate, calcium 
oxalate, and uric acid or urates. Five of the stones consisted largely of 
calcium oxalate, fourteen of calcium phosphate, and two of uric acid. 
Of the two stones consisting largely of uric acid, the composition of the 
first was a mixture of uric acid with calcium phosphate, and the second, 
a mixture of uric acid with calcium oxalate and phosphate. 

Errors in skiagraphing calculi may be due to several causes, great 
density of the parts, as in very stout persons, transparency of certain 
calculi, as of the uric acid type, diminutive size of the stone, faulty 
exposure, faulty development of plate, or any defect in the apparatus. 

I am in accord with the view expressed by Dr. Charles L. Leonard, 
that a positive or negative diagnosis of a urinary calculus should be 
based upon the findings on the negative, as the calculus should always be 
detected, if the negative shows a shadow of the least dense tissues. On 
a good negative, the shadows of the following structures should be 
visible : Shadows of the lumbar muscles, the transverse processes of 
the vertebrae, and the twelve ribs. 

D. URETERAL CALCULI. 

These are difficult to skiagraph, as the shadows of the pelvic bones 
superimpose upon the shadow of the calculi in the lower portion of the 
ureter. 

Of the 93 cases in which calculi were found, Leonard states that 
there were four in which calculi were present in the kidney and ureter 
of the same patient. Including these cases, 33 renal calculi were found 
and 64 ureteral. 

Tenny l has been able to add 33 cases of ureteral calculus since the 
publication of the 101 cases collected by Schenck. 2 The location of these 
stones has been in a general way in one of three places, depending on the 
physiological narrowing of the ureter. The first point of narrowing is 
about 7 centimetres down, and has a diameter of 3.2 millimetres. The 
second is just above or below the brim of the pelvis, and has a diameter 
of 4 millimetres, and the third is at a point just above the bladder, and 
has a diameter of 2.5 millimetres. The number of stones in the series of 

1 Boston Medical and Surgical Journal, Feb. 4, 1904. 
* Johns Hopkins Hospital Reports, vol. 10. 

23 



354 



ELECTRO-THERAPEUTICS. 



34 cases caught in the above locations corresponds very nicely in its 
diameters, 35 being caught in the first isthmus, 18 in the second, and 73 
in the third. In the remaining cases, the locations were not given. 

On the left side of the ureter, but sometimes on the right, is occa- 
sionally noted a sharp, round, white shadow corresponding to the lower 




FIG. 190. Reid's apparatus for renal skiagraphy. 

end of the ureter. This is caused by the presence of a phlebolith, which 
must not be mistaken for a calculus. Dr. Russell H. Boggs, of Pitts- 
burg, maintains that this shadow is due to a sesamoid bone. 

E. W. H. Shenton, 1 of London, believes that the fluoroscope is not 
sufficiently used in examinations for renal calculi. He advises placing 
the patient in a horizontal position, face downward, with the arms above 
the head. Efforts should be made to make the lumbar spine straight, 
even to the extent of placing a pillow beneath the abdomen. The tube 
should be placed beneath the patient 6 inches (15 cm.) from the abdomen, 
the actual distance varying according to the conditions of the tube and 
the size of the patient. The screen is placed upon the patient's back. 

A new apparatus for skiagraphing the renal region, devised by Mr. 

Archives of the Rontgen Ray, March, 1902. 



DISEASES OF THE ABDOMINAL ORGANS. 



355 



A. D. Eeid, of London (Figs. 190 and 191), and manufactured by Harry 
"W. Cox, Ltd., of London, dispenses with the use of compressors and is 
described as follows : The patient is laid upon the couch and an air cushion 
is placed under the part to be radiographed. The plate is then placed on 
the patient's back and the lead base with the upright arm is attached to it. 
"When the patient breathes the 
lead base is raised, the arm 
moves the lever up and causes it 
to make contact. 

This contact is merely a 
switch introduced into the pri- 
mary circuit of the coil, and 
consequently when it is closed 
the current is enabled to pass, 
and the tube fluoresces, simul- 
taneously the clock shown in 
the illustrations records the 
length of the exposure. 

It is, therefore, obvious that 
the kidney or any other part 
of the body must always be in 
the same position whenever the 
tube fluoresces. 

Dr. Albers-Schonberg be- 
lieves that the technic in renal 
skiagraphy has not been suffi- 
ciently studied. Hard tubes, he 
argues, should not be used. The 
shadows thrown by the last ribs 
and the transverse process of the 
first lumbar vertebrae are to be 
taken as guides. If nothing is 

seen at the first attempt, it should not be concluded that the result is 
negative. The plate should be intensified, and allowed to dry. This 
brings out many shadow details, previously invisible. To obtain the best 
effects the plate should be examined at a distance of 5 or 6 ft. If any 
specks are seen, which may possibly be due to calculi, another exposure 
should be made within three or four days. In any case of doubt a sepa- 
rate exposure should be made. A lead pipe with an opening of 13 cm. in 
diameter is placed close to the tube, and 50 cm. from the plate, so as 
to cut off the secondary rays and obtain a well-defined shadow. (Figs. 
192 and 193.) My time of exposure in renal skiagraphy depends upon 
the corpulence of the patient, and the degree of high penetrative power 
of the tube. The distance of the target from the plate is from 22 to 30 
inches (55 to 75 cm.). 




FIG. 191. Clock arrangement and break of the same. 



356 ELECTEO-THEEAPEUTICS. 

The method of examination of the kidney by the X-rays, when the 
organ is outside of the body during operation, has been fully described 
by the discoverer, Mr. Fenwick. 1 It consists in examining the kidney 
with the fluorescent screen after the organ has been removed as far as 
possible from the abdominal cavity. In some cases, he says, the kidney 
cannot be displaced out far enough to permit of a screen examination, 
due to insufficient length of the renal vessels. An objection to this 
method of examination is that the surgeon must necessarily remain 
in darkness for at least ten or fifteen minutes before he will be able to 
successfully perform a screen examination. 

F. Yoelcker and A. Lichtenberg 2 describe a process of pyelography. 
The ureter is catheterized, and the instrument is advanqed to the renal 
pelvis. A 5 per cent, solution of a silver salt is then slowly injected 
through the catheter. 

There are individual variations in the amount of fluid which the 
pelvis will tolerate : in one instance 5 c. c. gave rise to colicky pains, in 




FIG. 192. Compression diaphragm of Albers-Schonberg. (Kny-Scheerer Co.) 

others 50 to 60 c. c. could be introduced. The shadow cast by the rays 
will reveal any abnormality, such as a kinking, bending, constriction, or 
dilatation of the ureter. 

The authors employed the procedure in eleven cases, ten being 
women and one a man. In four of their cases, their efforts were unsuc- 
cessful. The operation is not very painful, but is more easily done after 
an injection of morphia. 

I present the following as a few of my cases, showing the value 
of skiagraphy in determining the presence of nephritic calculi : 

In the Medico-Chirurgical Hospital' in 1901, I examined a case for 
Drs. Rodman and West, but found only an enlarged kidney. The 

J The British MedicalJournal, Oct. 1C, 1897. 

2 Munch, med. Wocl)., January and October, 1906. 



DISEASES OF THE ABDOMINAL ORGANS. 



operation confirmed the diagnosis. In 1900, at the same hospital, I skia- 
graphed a case for Dr. Elwood E. Kirby, and, instead of a calculus, I 
found a collection of pus ; this was subsequently confirmed at operation. 




FIG. 193. The same, postero-anterior view. 

For several years I made an annual examination of a patient, under 
the care of Dr. Ernest Laplace. The negative showed a calculus in the 
pelvis of the kidney, which was subsequently removed. (Fig. 194.) 

In a case under the care of Dr. Alfred Stengel, I found a calculus in 
the pelvis of the kidney, that for three years occasioned an unceasing 
dull pain. Dr. Charles H. Frazier removed the stone at the University 
Hospital. 

At the Philadelphia Hospital in 1903, I skiagraphed a renal calculus 
for Dr. J. B. Garnet, which was successfully removed. 

In 1904, at the same hospital, Dr. Ernest Laplace operated for a sup- 
posed case of appendicitis. After the operation the pain continued, and 
three weeks later a skiagram revealed a calculus in the kidney. This was 
removed, and the patient at once recovered. 

E. THE BLADDER. 

Examination for Calculi. The preparation required is the same as 
for a renal examination, and in addition the bladder and rectum should 
be emptied just prior to the exposure. The patient should be placed 
upon the table in the ventral position. The plate, or preferably two, 



358 ELECTRO-THEKAPEUTICS. 

well protected, should be laid under the pelvis. The table is tilted so 
that the head will be much lower than the feet, an expedient for bringing 
the calculus as much above the pubis as possible, thus avoiding super- 
imposition of the shadows of the calculus and the bone. The tube is 
placed so that the rays will be parallel with the sacrum and pass through 
the true pelvis without causing any superimposition of the shadows on 
the negative. Skiagrams produced with the patient lying on the back 
have been very satisfactory in my experience, especially so in corpulent 
subjects, by placing the tube above the umbilicus. 

In Pig. 195 is shown the skiagram of a large vesical calculus. At a 
prominent Philadelphia hospital, the case was incorrectly diagnosed as 
an enlargement of the prostate. The patient became progressively worse, 
and as a victim of neurasthenia, he applied to the Kervous Department 
of the Medico-Chirurgical Hospital, 1901. Dr. Ellwood E. Kirby sug- 
gested the wisdom of an X-ray examination, when the large calculus, here 
shown, was found. The patient was operated upon and made a perfect 
recovery. 

Englisch l describes a total of 405 cases of calculi in the urethra or 
diverticulurn. He classifies them in various groups, and discusses each 
in turn. The stones were in the membranous portion in 149 instances, 
and in the bulbous urethra in 68 cases. 

Closure of tJie Bladder, as shown Skiagraphlcally. Leedham-Greeu * 
found that, whether the bladder was fully distended or not, the outline 
of the organ was oval, not pyriform, and the urethra was sharply cut 
off from the bladder without a suggestion of a bladder neck. There are 
reasons, therefore, for believing that the sphincter of the bladder plays a 
more important part than Finger and Guy on credit it with, and that 
under ordinary circumstances it is by this muscle that the bladder is 
closed, whether distended or not. 

F. PROSTATIC CALCULI. 

F. Frank Lydston * reports that a farmer aged 34 was fallen upon by 
a horse, and the perineum sustained a severe blow. Haematuria followed, 
without obstruction of the urethra, and he was apparently well in 10 
days. Six months later there was difficulty in micturition ; he passed 
several small calculi, and has done so at intervals since. Examination 
revealed an apparent calculus at the bulbo-membranous junction, with 
enlargement of the prostate. Operation was advised, and through a peri- 
neal incision a calculus weighing 720 grains was removed from the pros- 
tate. Lydston believes that, as a consequence of the traumatic stricture, a 
certain quantity of residual urine continually remained in the canal, 

1 Arch. f. klin. Chir., Berlin, 1906, p. 743. 
* Archives of the Rontgen Ray, May, 1906. 
s Annals of Surgery, March, 1904. 







c.r. 



FIR. 194. Calculus in the pelvis of the riht kidney. (Case of Dr. Laplace.) 



DISEASES OF THE ABDOMINAL OKGANS. 359 

decomposition followed, with the formation of secondary calculi. The 
obstruction caused dilatation of the prostatic ducts, small secondary 
calculi were forced into the latter, and one of these became enlarged, 

' O ' 

forming a nucleus about which was deposited the material which 
resulted in the formation of the large stone. Stricture of the urethra 
may at times be detected by injecting bismuth solution and then taking 
a skiagraph. (For biliary calculi, see chapter on The Alimentary 
System. ) 
Rdntgenogra/phy of the Urinary Bladder After Oxygen Insufflation. 

To the radiologist it is often a perplexing question to determine, 
when examining the pelvis for the presence of calculi, whether the 
shadow represents a concretion within or without the urinary tract. 

Volker Lichtenberg doses his patient with collargol, so that the 
urinary tract may be mapped out by the deeper shadow, due to the 
presence of silver. 

Another method is to pass into the ureter a catheter which is made 
of some material opaque to the rays, and to note the relation of the 
shadow cast to that of the catheter. 

Wittek, in 1904, was the first radiographer to fill the urinary 
bladder with air prior to taking a skiagram of a suspected calculus. It 
has been Albers-Schonberg's practice to innate that organ with oxygen. 

The method pursued by Morgan l is to take a radiograph stereoscopic- 
ally and to examine the plates in a stereoscope. 

Even with a vesical calculus of large size, obscuration of its shadow 
may be due to the distance of the part from the plate and the thickness 
of the intervening structures (the patient lying in the dorsal position 
with the plate beneath him); or to the presence of urine in the bladder 
and of faeces in the rectum. 

The technic is as follows: 

The rectum is to be emptied by administering a purge the day 
before, and an enema on the morning of, the examination. The radio- 
graph is taken with the patient lying upon his back or face, the plate 
beneath him and the Crookes tube above. As the patient is placed upon 
the table, a soft catheter is passed and the urine drawn off. Without 
withdrawing it, the catheter is then connected with an oxygen generator 
whose .tap is cautiously turned on, so that the oxygen enters the 
bladder at not too great a pressure. 

After the radiograph has been taken, Morgan re- introduces the 
catheter and draws off some of the oxygen. What is left the patient 
passes with the urine. The only discomfort of which he complains is 
the pressure of the distended bladder. 

1 Archives of the Rontgen Ray, vol. xii, No. 92, March, 1908. 



360 ELECTEO-THEEAPEUTICS. 

The advantages of the method are that you obtain a clear picture of 
the outline of the bladder and its contents and are enabled to state defin- 
itely as to whether a shadow represents anything inside or outside the 
bladder wall. It also shows any irregularity of the surface, such as 
might be caused by chronic cystitis, tuberculous deposits, villous growths, 
or tumors. 

My own technic, which differs very little from the above, I have 
employed for many years, in a large number of cases, for rectal as well as 
for vesical examinations. In the rectal procedure, I was frequently 
enabled to obtain a clear picture of the coccyx, and by distention of the 
intestinal walls, there were frequently revealed the presence of abdominal 
tumors. 

Exploration of Fistulous Sinuses and Abscess Cavities by the 
Bismuth Emulsion Method. 

The older methods of exploring sinuses and fistulas are quite ineffi- 
cient in determining the boundaries of these suppurating channels. The 
probe may successfully enter one sinus, whilst the surrounding area may 
be undermined with a network of sinuses. The injection of milk or col- 
ored fluid may run through a large patulous sinus, the narrow ones 
remaining collapsed, because of insufficient pressure to distend them. 
The stained tracts become covered with blood and, besides, no one can 
study the extent of disease before operation. 

The only satisfactory method extant of exploring the boundaries of 
these tracts and cavities is by the bismuth emulsion process. 

Although I had successfully used this measure some six or seven 
years ago, in a case of imperforate rectum, by introducing the solution 
into the rectum, through an artificial anus, the procedure is again 
brought forward by Dr. Emil G. Beck of Chicago, 1 whose method may 
be described as follows: 

He fills the tract or cavity under moderate pressure with a paste 
made of 33 per cent, bismuth subnitrate and 66 per cent, vaseline, and 
takes a radiograph of the region so injected. If the radiograph be made 
stereoscopic, one may readily discern distinctly the extent, ramifications 
and tortuosities of the sinuses. 
MODUS OPERANDI. 

A paste of 30 grammes of bismuth subnitrate and 60 grammes of 
white vaseline is made by boiling the latter and gradually stirring the 
dry bismuth into it. Cleanse the mouth of the fistula with alcohol ; a 
fine strip of sterile gauze should be placed into the opening. 

A glass syringe with a blunt nozzle is then sterilized by a dry proc- 
ess and charged with the paste while in a liquid state. The nozzle is 
pressed against the opening and the contents gradually forced into the 
1 Archives of the Runtgen Ray, vol. xiii, No. 1, June, 1908. 



DISEASES OF THE ABDOMINAL OEGANS. 361 

fistula until the patient complains of the pressure. The syringe is then 
removed and a piece of gauze quickly placed against the opening, to pre- 
vent the escape of fluid, until it has sufficiently hardened. An ice-bag 
may be applied to hasten the solidification of the paste within the fistula. 
Care should be taken that no water is mixed with the paste. The part is 
then ready to be radiographed. 

It is worthy of note that the bismuth injection in conjunction with 
some minor details is not only of diagnostic value but curative as well. 
A number of cases have been permanently cured by injecting this paste 
for Eontgenological purposes. 1 

1 Journal of the American Medical Association, March 14, 1908. 



CHAPTER VI 
APPLICATION IN THE SPECIALTIES. 

I. Obstetrics and Gynaecology. 
OBSTETRICS. 

IN radiographing the uterus and its contents much difficulty is 
encountered, as in this part of the body the rays will have to penetrate 
many thicknesses of tissues ; but, if the abdominal wall is not too fat, fair 
results may be expected. Another obstacle is, the refusal of the patient 
to remain in a constrained position for a sufficiently long time to obtain 
the desired results. 

The distance of the sensitive plate from the uterus, the movements 
of the foetus, and of the uterus itself, and the respiratory movements of 
the mother, are obstacles to satisfactory results. 

Pelvlmetry. A new process of pelvimetry devised by Dr. Henri 
Varnier 1 demands brief attention. "When a radiograph is to be ob- 
tained, the operator arranges the X-ray tube at a short distance from 
the part to be radiographed, usually varying from 16 to 24 inches (40 to 
60 cm.). The result is that, since the radiographic negative registers 
only the projected shadows of the object, the image obtained is some- 
what larger than the original, at least for all the parts of the latter not 
in direct contact with the sensitive plate. 

In order to surmount this difficulty, Dr. Varnier removed his source 
of Eontgen rays to a distance sufficient to permit them to behave practi- 
cally the same as if they were parallel. He has shown that the rays may 
come from a considerable distance and the ordinary double anode tul>es 
can be employed. 

"With a coil of 10 inches (25 cm.) spark and provided with a Ducretet 
vibrator, he has been able, in an exposure of ten minutes and with a current 
of 10 amperes at 26 volts, to obtain the outlines of a dry pelvis upon a 
photographic plate placed at a distance of 25 metres from the Crookes 
tube, and in an exposure of 20 minutes the- same outlines were obtained 
upon a plate 30 metres distant. It is usually better not to resort to such 
distances, thus obviating long exposures. 

At a distance of five metres the usual instruments of measurement 
do not show any difference between the dimensions exhibited by the 
object and the radiograph. For ordinary exigencies a distance of 2.5 
metres is sufficient, as shown in the following measurements by Dr. 
Varnier of a dry pelvis. The error found is of the same nature and 

Scientific American, May 1, 1901. 
362 



APPLICATION IN THE SPECIALTIES. 



363 



never exceeds 5 millimetres, i. c., it is practically nil. The modus 
operandi is extremely simple. The Crookes tube is placed at a distance 
of 2.5 metres (98 inches) from the plate, with its cathode perpendicular 
to the long axis of the upper brim of a normal pelvis, taken as a point 
of observation. 

The following table was compiled by Dr. Varnier from experiments 
and measurements with a dry pelvis, and in it will be found the differ- 
ence between the dimensions of the pelvis itself and the radiograph : 



MEASUKEMENTS MADE 


DRY PELVIS 


RADIOTYPE 


DIFFERENCE 


Maximum transverse diameter 


mm 
122 

114 
118 

103 
32 
235 
250 


inches 
= 4.803 

= 4.488 
= 4.645 

= 4.055 
= 1.259 
= 9.281 
= 9.842 


mm 
125 

117 
121 

108 
33 
235 
250 


inches 
= 4.921 

= 4.606 
= 4.763 

= 4.251 
= 1.299 
= 9.251 

= 9.842 


mm. 

+3 = 

+3 = 
+ 3 = 

+5 = 
+ 1 = 

I A 

-o = 


inch 
+0.118 

+0.118 
+ 0.118 

+0.196 
-t 0.040 

+ .0 
+ -o. 


Antero-posterior diameter (the only 
measure up to the present) 


Left oblique diameter 


Transverse bi-ischiatic (the part 
farthest from the plate ) 

Width of the first piece of the 
coccyx 


Distance of the anterior and posterior 
iliac bones 


Transverse diameter of the greater 
pelvis 





Along the line A B (Fig. 196) taken as a base, he arranges in his 
frame a 40 x 50 centimetre (15.74 x 19.68 inch) sensitized plate. The dry 
pelvis is then placed in pronation (i. e., with the front downward) with 
the line of crests resting upon C D and its antero-posterior diameter in 
line with E F. 

In order to operate upon a living person, it suffices to replace the 
dry pelvis by the subject to be examined, who must lie so that the pelvis 
will assume the same position. By using the data given, the measure- 
ments may be accurately obtained. 

The patient can be made more comfortable by employing the 
author's tube-holder and table, placing the tube under the table and 
having the patient assume the dorsal decubitus position ; often the 
Trendelenburg position is useful, because of the gravitation of the 
abdominal contents toward the diaphragm, thereby lessening the 
obstruction to the rays. 

Contremoulins, 1 of Paris, takes two skiagrams, with the tube in two 

1 Bouchard, "Traite Radiologie Medicale," p. 1010, a contributed article by 
M. Fabre. 



364 



ELECTKO-THEEAPEUTICS. 



different positions, without disturbing the patient or altering the plane 
of projection. The first negative is taken and then removed, and a 




FIG. 1%. Varnier's arrangement for radiography. 

second plate is placed in the same position. In each instance the normal 
point of incidence is indicated on the skiagram. A tracing of the salient 
points is made, to be ultimately transferred to a zinc plate. Threads are 
stretched from points in the latter by which the two cones of projection 



APPLICATION IN THE SPECIALTIES. 365 

may be redrawn, their apices corresponding to the two positions of the 
Crookes tube. The intersection of these cones is an index of the position 
and size of the pelvic inlet. 

Stereo-skiagraphy of the pelvis is the best method to employ in 
pelvinietry and for the study of pelvic deformities. 

The data given in the above table are those used in the special radio- 
graphic department of the Baudelocque clinic, founded by Prof. Pinard 
and Dr. Yarnier. 

Williams 1 says : "In order to determine the transverse diameter of 
the superior brim of the pelvis, the following method has been devised 
by me, by which the two halves of the pelvis are taken separately, but 
on the same photographic plate. The patient lies on her back on a 
stretcher, with the plate over the abdomen and the inlet of the pelvis 
about parallel with the plate. When the right side of the pelvis is being 
taken, the left half of the plate is shielded by a sheet of lead placed 
under the plate. The tube is placed by means of a plumb line as nearly 
as possible directly under the right border of the superior brim of the 
pelvis, in the line of the pelvic axis 3 centimetres to the right of the 
median line. If the tube is at least 60 cm. from the plate, the distortion 
in the photograph will not be great. After the first exposure has been 
made, and the left side of the pelvis is to be photographed, the sheet of 
lead is moved so as to cover the right half of the plate and the tube is 
placed immediately over the left edge of the superior outlet of the pelvis, 
3 cm. to the left of the median line. Its proper position being obtained 
by means of the plumb line, the photographic plate is not disturbed. 
An exposure is then made of this part, and, thus, a photograph of the two 
sides of the brim of the pelvis is obtained. By this method the error 
due to the slanting direction of the rays falling on the pelvic brim and 
the plate when only one exposure is made for both sides is avoided, 
and no calculation is necessary to estimate the amount of exaggeration, 
as in the latter case." This method is applicable to non-pregnant 
cases. With the gravid uterus the plate cannot be brought in contact 
with the part. 

A skiagraph of the foetus may be produced quite readily after it has 
been taken from the uterus. In 1896 Dr. Oliver diagnosed one ectopic 
gestation, six weeks beyond term, in a woman aged 39 years. An attempt 
was made to radiograph the mass within the abdominal cavity, but the 
result was altogether unsuccessful. Operation proved the presence of 
an ovarian sac, which contained a nine-months' foetus. After its removal 
by operation a successful skiagram of the foetus was produced. Human 
foetuses in various stages of development are to-day quite readily and 
successfully skiagraphed. The older the foetus the better will be the 
resulting skiagraph. 

1(< The Rontgen Rays in Medicine and Surgery," p. 379. 



366 



ELECTKO-THERAPEUTICS. 



Gravid Uterus. I have been able to produce, in a few cases, skia- 
grams of gravid uteri. Dr. E. P. Davis 1 states, that his experiments 
showed that it is possible to obtain an outline of the living foetus *in the 
body of the mother, notwithstanding the thickness of the tissues, and the 
distance at which the Crookes tube is necessarily placed from the foetus. 
I made several stereo-skiagrams of pregnant women at the Philadel- 
phia Hospital for Dr. Davis, and the result was eminently successful. 

Anatomical specimens of uteri, and their contents, removed from the 
body should occasion no difficulty. By varying the current and the time 
of exposure, it is undoubtedly possible to obtain a useful picture of the 
contents of the living womb. 

Drs. Henri Varnier and Ed. Pinard have diligently studied the 
gravid uterus, both in the living and the dead, by means of the Rontgen 
rays. In the case of a woman dying from uraemia, they were enabled to 




FIG. 197. Author's head rest for stereoscopic work. 

show the head of a seven-months' foetus at the superior strait. In the 
second case, after death from some form of lung disease, they were enabled 
to show the contour of the uterus, together with a part of the vertebral 
column of the contained foetus. 

Queirel and Acquavita 2 assert that the evolution of the osseous sys- 
tem is demonstrable, at premature birth, by the skiagraph, and hence 
the determination of the age of the developing foetus assumes an impor- 
tance in matters of medico-legal interest. 

1 American Journal of the Medical Sciences, March, 1896, p. 268. 
'Bouchard, "Trait6 Radiologie M&licale," p. 1009. 



APPLICATION IN THE SPECIALTIES. 367 

GYNAECOLOGY. 

So far the X-rays have been of little practical value in gynaecol- 
ogy. Before long, however, correct diagnoses of various tumors, cysts, 
abnormal positions of the uterus, diseases of tubes and ovaries, etc., will 
undoubtedly be made by means of the Kontgen rays. At present the 
shadows produced upon sensitive plates of the various conditions of the 
pelvic and abdominal organs (except the bladder and prostate) are 
insufficient in detail. Dr. Eden Y. Delphey l says, that the main use of 
the X-rays in gynaecology lies in the treatment of malignant disease, and 
when a diagnosis is made sufficiently early, the neoplasm and often all 
the pelvic reproductive organs should be removed by surgical means, so 
as to get entirely beyond the malignant growth and prevent recurrence. 
"When this can be done, the protuberant portion should be removed and 
the remainder subjected to the influence of the Rontgen rays. 

II. Rhinology, Laryngology, and Otology. 

The X-rays are at present coming into use in affections of the nose, 
throat, and ear. 

EiHINOLOGY. 

A screen examination of the nasal bones, when displaced, depressed, 
or fractured, is well illustrated by this means. If supports, as silver or 
aluminium splints, are placed under the depressed bones, their correct 
position may easily be ascertained by a screen examination ; the same 
holds good for exostoses and foreign bodies. Abscesses of the antrum 
and frontal sinuses may be readily skiagraphed, and I find for these cases 
head rests (Figs. 197 and 198) most valuable. 

Diseases of the frontal sinuses may be skiagraphed in the occipito- 
frontal and lateral positions. The former is difficult, because of the 
thickness of the skull. By this view we note on the plate the presence 
or absence of these sinuses, also their size, shape, symmetry or asymmetry, 
the number of septa, the presence of contained morbid products, and the 
extent of the orbital and ethmoidal recesses. The skiagraph in the lateral 
position is easier of accomplishment, but it fails to show the details above 
mentioned, because only one side is taken and therefore forbids compari- 
son ; but it shows clearly the ethmoidal and orbital recesses and the 
sphenoidal sinuses. Both views should always be skiagraphed. Theden- 
tiaskiascope, or endodioscope, first described by Dr. Macintyre and used 
for examining the hard and soft tissues about the bones of the face, nose, 
and larynx, deserves mention. Dr. Macintyre writes as follows : 2 " The 
fluorescent screen is placed inside of the mouth and theCrookes tube out- 
side, or vice versa. Small disks of glass are coated with the fluorescent 

1 Annals of Gynaecology and Pediatrics, Feb., 1903. 

2 Glasgow Hospital Reports, 1898, p. 306. 



368 



ELECTRO-THEKAPEUTICS. 



salt and covered with aluminium, or tongue depressors consisting of flat 
strips of glass covered and coated in the same way may be employed. By 
placing the tube outside, I am able to get an image of the septum and 
other parts of the cavity of the nose, on the fluorescent screen in the 
mouth. In the same way the roots of the teeth may be seen. If the 
surgeon desires to examine the tissues externally, i. e., to pass the 




<s> 



FIG. 198. AUTHOR'S HEAD REST FOR SKIAGRAPHING DISEASES OF THE FRONTAL SINUSES. With 
this device, the patient is seated and his head or face is applied to the board. There are two movable 
padded head rests, one on the vertex and the other under the occiput ; the chin is supported on a rest. 
P. II. is a plate-holder lined with a transparent material, into which the sensitive plate can be slid or 
inserted. It is also very convenient for stereoscopic work. This plate-holder can be adjusted according 
to the angle of the face and forehead, as shown in the scale, and fastened at any angle. I find that a 
30-degree angle is the best position for the patient. This angle is formed by the glabella G, the exter- 
nal auditory meatus, and the anode of the Crookes tube. As the facial angle vnries in different individ- 
uals, it is necessary to adjust the tube accordingly. The more obtuse the facial angle, the more acute 
should be the angle between the bundles of rays and the base of the skull, or a line connecting the 
external auditory meatus and the glabella. The more acute the facial angle, the more obtuse should 
be the angle formed by the tube. The X-rays should form as near a right angle to the plate as possible, 
always avoiding the shadow of the occipital bone. If the rays are directed through the cervical region, 
the shadows of the vertebrae will throw irregular shadows over the sinuses. I find that this is un- 
satisfactory. 

rays through the neck, we can place a small fluorescent screen on 
one side and remove the Crookes tube to a suitable distance. By this 
means I have been able to demonstrate the presence of foreign bodies, 
and need hardly add that they are more easily photographed." 

Monnier 1 is able to diagnose the etiological factors of a chronic 



1 Archives Internal, de Laryngologie, November 3, 1898. 






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APPLICATION IN THE SPECIALTIES. 369 

post-nasal suppuration associated with epiphora. He gives as the cause a 
piece of a lacrymal sound which had remained in the nasal duct for some 
twenty years. 

LARYNGOLOGY. 

While the X-rays have accomplished but little in the department of 
laryngology, they have proved of great service in the detection and 
accurate localization of foreign bodies in the upper portion of the diges- 
tive and respiratory tracts, thus aiding the laryngologist to decide as to 
the advisability and character of operations for their removal ; also in 
the determination of the ossification of structures in the laryngeal and 
tracheal cartilages. At present we can ascertain with scientific accuracy 
the time and the points at which all the cartilages ossify. The X-rays 
aid in the diagnosis of intra-thoracic growths involving the respiratory 
tract, either by compression of the trachea, or by some form of vocal-cord 
paralysis. They are also likely to prove useful in the earliest detection 
of any tuberculous processes in the lungs. The observer must be trained 
to this line of observation in order that perfection may be obtained. The 
delicate variations in the shadows that form on the fluorescent screen can 
be properly interpreted only by practice. Fig. 199 shows the presence of 
a tumor in the trachea. 

OTOLOGY. 

The rays have been of slight value in otology. In two cases where 
foreign bodies had been introduced into the ear, I was able to detect and 
localize them by means of the X-rays. In each instance the external 
auditory canal was greatly inflamed and swollen, so as to prevent an 
ordinary examination of the part with a satisfactory result. 

The diagnosis of mastoid abscess by the X-rays is feasible. Three 
cases examined by me showed the presence of abscesses, and subse- 
quent operations confirmed the diagnoses. In all these cases the nega- 
tives showed a dense shadow instead of the porous appearance found 
normally. 



CHAPTER VII 
APPLICATION IN DENTISTRY. 

THE employment of the X-rays in dentistry has opened up a prom- 
ising field. 1 Thus far skiagraphy has rendered invaluable aid, assisting 
the dental surgeon in diagnosticating perplexing conditions and in con- 
firming conclusions previously obtained. Thus, the position of the roots, 
the occurrence of fracture of a root, the presence of alveolar absorption, 
the existence of fluid in the antrum, and many other pathological states 
and conditions are readily revealed to us through this method of 
investigation. The structure and evolution of the teeth can be studied 
in the living subject. 

I. Apparatus Used in Dental Skiagraphy. 

The paraphernalia and technic employed in dental skiagraphy do 
not differ from those used for other regions of the body. A small coil of 
6- or 7-inch spark length is sufficient. For the denser structures, as, for 
instance, the entire thickness of the maxillary bones, a tube of high 
vacuum is essential ; the same kind of tube should be employed where 
the skiagram must be taken rapidly, and where the exposure is con- 
sequently short, as in cases of children. 

II. Technic. 

Fluoroscopic examinations in dentistry do not yield satisfactory 
results. The two methods at present employed in dental skiagraphy are 
the intra-oral and the extra-oral or buccal. 

The intra-oral method consists in inserting a small piece of film (light 
and moisture proof) over the alveolar tissue where trouble is suspected, 
and in adjusting the tube so that perpendicular rays will fall upon the 
teeth and film. A small sensitive plate, being inflexible, cannot be made 
to adapt itself to the curvature of the part. Rollins, of Boston, encases 
the film in an aluminium cover, while Price, of Cleveland, Ohio, uses 
unvulcanized black dental rubber, protecting the emulsion with a sheet 
of sensitive bromide paper. Kodak films cannot be used for this 

1 The first skiagraph of the teeth was exhibited by Prof. Koenig, to the Society 
of Physics of Frankfort-on-the-Main, in February, 1896. 

In April, 1896, at the Congress of Erlarrgen, Walkoff demonstrated many skia- 
graphs of the teeth in living subjects. (Bouchard, " Traite Radiologie Medicale.") 

Dr. William J. Morton on "The X-rays in Dentistry," which appeared in 
Dental Cosmos, June, 1896, reproduced from his book : " The X-rays, or Photography 
of the Invisible.' ' 
370 



APPLICATION IK DENTISTRY. 371 

purpose. Formerly I preferred a specially prepared, thick, double- 
coated film, which I cut to the required size and enclosed in a layer of 
black paper, after which the paper was so folded as to enclose snugly 
the film, and the whole placed in a yellow envelope just large enough to 
accommodate the size of the paper and film ; the smooth side correspond- 
ing to the sensitive side of the film. Lately I have much preferred 
Eastman's negative transparent films, which are neatly encased and 
always ready for use. 

Place the patient in the dental chair and adjust the tube. See that 
the rays fall perpendicularly to the vertical axis of the teeth. If the 
adjustment of the tube is faulty, the shadows of the teeth will be 
distorted. In order to include, in the skiagraph, the roots of the teeth 
place the film against the hard palate. Before its introduction into the 
mouth, the enveloped film should be reinforced by a couple of rubber 
bands. Skiagraphic work on the superior maxillary bone is less satis- 
factory than upon the inferior maxillary, as the film cannot be brought 
in a line parallel with the teeth. Two films can be exposed at one 
time. As only one or two teeth can be included, the film should be 
pressed against the affected part, the exposure varying from two to ten 
seconds. By this method sharper definition on the negative is obtained, 
and only a small area is skiagraphed. 

The extra-oral or buccal method (Fig. 200) requires a plate 8 x 10 to be 
brought in contact with the jaw at the suspected region. A block of wood 
is wedged between the widely extended jaws, and the patient is directed 
to lie upon the affected side, and to incline the head and neck to an angle 
of about 45 degrees. The tube is now placed on the opposite shoulder, the 
latter is protected by a sheet of lead (the tube being placed very close to 
the shoulder), and the rays are sent obliquely at a distance of 20 to 25 
inches (50-63 cm.) from the face, to avoid overlapping of the shadows 
of the jaw. This method produces a picture of great area, and is 
intended for bicuspids and molars of both jaws. Exposure varies from 
half a minute to two minutes. 

Dr. Sinclair Tousey, 1 of New York City, thus describes, " A new 
film-carrier and indicator for dental radiography with projection upon a 
horizontal plane." 

" It consists of a stiff card two and one-half inches (6 cm.) wide and 
five inches (13 cm.) long, covered at one end by a sheet of rubber dam, 
which forms a pocket into which the film, wrapped in black paper, may 
be slipped. This end is placed horizontally in the patient's mouth, and 
held there, by tightly closing the lips and teeth. The part of the card 
which projects from the patient's mouth has a clamp of aluminium, 
which may be turned to either side or straight, and carries a thin 
aluminium rod which is always held at the proper angle to the plane of 

1 Archives of Physiological Therapy, September, 1905. 



372 ELECTRO-THERAPEUTICS. 

the film. Diagrams of the teeth are printed upon both the upper and 
lower surface of the card, and serve to indicate the position to which the 
aluminium pointer must be turned laterally. 

"For radiographing the upper jaw the patient sits erect with a film- 
carrier in his mouth. The pointer is turned to the position on the dia- 
gram where the teeth of chief interest are located, and the X-ray tube in 
a Friedlander shield is brought into a position to correspond with the 
position of the pointer. In other words, we have an aluminium rod 
which points to the spot where the anticathode of the tube should be 
placed. For the lower jaw, a film-carrier is turned down, and it will 
often be found desirable to tilt the patient's head somewhat, in order to 
cause the indicator to point to a spot at which it is practicable to place 
the X-ray tube. It is hardly necessary to add that, since the incisor 
teeth are an inch behind the pivot of the indicator, the auticathode must 
be placed in corresponding relation to the pointer. 

"The value of the film-carrier and indicator lies in the fact that it 
readily and securely holds the film in position, without placing the 
finger inside the patient's mouth. The proper relation of tube and film 
are very readily acquired. The picture obtained gives an exact measure 
of the length of the teeth, and, most important of all, the teeth of the 
whole side or front of the jaw may be shown on one film. By using an 
unusually wide film, it is practicable to secure a picture of very good 
definition, of the teeth of both sides of the lower jaw, and also of the 
incisor teeth, but the latter, of course, would be a confused overlap- 
ping mass. The radiograph of the upper jaw may show all the front 
teeth, or, if taken at the side, all the side teeth and the antrum of 
Highmore. To get the wisdom-teeth, either upper or lower, the back of 
the film must be held far back in the mouth, but this is less unpleasant to 
the patient than the more usual way of pressing a small film against the 
inside of the jaw far enough back for that purpose. The greater ease 
with which it is practicable to show the entire vertical width of the lower 
jaw is an additional advantage." 

III. Clinical Applications. 

Unerupted Teeth. An important condition coming under the dentist's 
care is the retention or non-eruption of a permanent tooth, owing to the 
temporary tooth remaining in the alveolar socket, beyond the age con- 
sidered normal. If the skiagram reveals the unerupted tooth to be of 
normal shape and so located as to permit of its eruption, the indication 
is to remove the temporary tooth. Many cases of odontalgia are un- 
doubtedly due to an unerupted tooth ; in such cases the etiological factor 
may be revealed by the X-rays. (Figs. 201, 202, 203, 204, 205, 206.) 

Necrosis of tlie Maxilla. Necrosis of the superior or inferior maxillary 
bone can readily be shown by careful X-ray examinations. (Fig. 207.) 




Fro. 200. EXTRA-ORAL METHOD IN DENTAL SKIAGRAPHY. LS, lead screen for the protection of 
the operator. The arrows indicate the variable positions to which the author's tube-holder may be 
shifted. The illustration depicts the sensitive plate placed upon a book and the lad's left (suspected 
ide) cheek resting on the plate, the dotted line shows the path of the rays. 




FIG. 201. UNERUPTED TEETH. Malposition of the wisdom tooth in the lower right jaw and delayed 
eruption of the wisdom tooth in the right upper jaw, the latter indicated by dotted lines. 




FIG. 202. UNERUPTED UPPER CUSPID TOOTH. The patient presented a swelling at the ala of the nose 
with reflex nasal and crbital symptoms. (Case of M. II. Cryer.) 




FIG. 203. DELAYED ERUPTION OF THE UPPER CUSPID TOOTH. The bridge is separating the first from 

the lateral teeth on each side. 




FIG. 204. DELAYED ERUPTION OF THE UPPER CUSPID TOOTH. The temporary teeth are in situ. One 
of the latter was removed, when the permanent cuspid tooth was detected. 




FIGS. 205, 206. Delayed second bicuspid on both sides of the lowor jnw, in a girl of 12. The upper 
picture is the right side of lower jaw, and the lower the left side ol f lower jaw. (Case of Drs. Cryer and 
Smith.) 




FIG. 207. PHOSPHOROUS NECROSIS OF THE INFERIOR MAXIU.A. Dotted area shows the portion of bone 

removed. (Case of Dr. Cryer. ) 




FIG. 208. CHRONIC ALVEOLAR ABSCESS OF THE RIGHT CENTRAL INCISOR TOOTH. Patient, age 18, 
treated for the above condition for a period of four years, having six sinuses on the labial surface of 
the gum. X-rays reveUed remnants of foreign body at the apex of the root. Dr. C. F. Horgan removed 
the tooth (right central incisor), and, after cleaning and filling, the tooth was reimplanted. Two years 
later the patient remained absolutely well, and the tooth is giving good service. 



APPLICATION IN DENTISTRY. 373 

A necrotic condition of the jaw, especially when advanced, as in phos- 
phorus poisoning, gives the skiagram a lighter area than is produced by 
the adjacent unaffected bone. In a few cases that have come to my notice, 
I have observed a peculiar condition, namely, an irregular arrangement 
of the teeth, failing to remain in the sockets, as seen normally. The light 
area produced by necrosis is undoubtedly due to a decrease of organic 
material, replaced partially by an increased amount of inorganic salts. 
In a case, referred to me by Dr. Cryer, the patient presented a swell- 
ing at the angle of the lower jaw. A skiagraph showed the absence 
of true osseous tissue. The part was curetted, and, three months later, at 
a clinic at the Philadelphia Hospital, the skiagram revealed a regenera- 
tion of the osseous tissue. 

Ankylosis of the Inferior Maxillary Articulation. This may be true or 
false, partial or complete, depending upon the cause. Fluoroscopic 
examinations in this condition are unsatisfactory, except for observing 
the movements of the temporo-uiaxillary articulation. The skiagram is 
taken by the extra-oral method. A negative showing the affected joint 
in the early stages usually presents an irregularity of the articulating 
cartilaginous surfaces. In true aukylosis, as when following a fracture 
involving a joint, the latter may be seen to be wholly obliterated. In 
false ankylosis, the joint is seen to be much eroded, the fibrous adhesions 
not being evident unless they have become partially infiltrated with 
inorganic salts. 

Fracture of the Inferior Maxillary Bone. For this injury employ the 
methods before described. In fracture of the symphysis, the plate should 
be placed under the chin, the inferior maxilla being fully extended, in 
order that the rays may penetrate the injured part from above. Some 
prefer to place within the oral cavity a film, and have the rays pass 
from the outside, as employed for unerupted teeth. The progress of repair 
in this fracture, as well as in others involving this bone, may be easily 
determined by frequent fluoroscopic examinations. 

Broken Instruments. Not infrequently a dentist, in his endeavor to 
fill the root canal, breaks an instrument, the fragment remaining inside 
the cavity. In his endeavor to remove the particle, he may cause it to 
become lodged more tightly and further up in the cavity. An X-ray 
examination will enable him to decide upon a course most suitable for its 
early removal. 

Root- Canal Fillings. An X-ray examination will demonstrate whether 
a canal has been properly filled or not. Such an examination after the 
filling of a root-canal would accomplish much toward the prevention of 
an alveolar abscess. 

Abscess of the Antrum. Pus or other fluid in the antrum of Highmore 
may readily be seen by careful fluoroscopic examinations. The X-rays 
are eminently practicable in diagnosticating various diseases of the 
antrum. Foreign bodies, as roots of teeth, are located with exactness, 



374 ELECTRO-THERAPEUTICS. 

and the relations of the teeth to the antrum or abscesses about them may 
clearly be demonstrated, also the position and shape of the floor of the 
antrum, the presence of fluid or pus, etc., which may be contained 
therein. 

Alveolar Abscess. Dead pulp in a tooth indicates a break in the con- 
tinuity of the pericemental membrane at the apex of the root, and more 
or less absorption of the adjacent osseous tissue, and occasionally of the 
roots in long-standing cases. In the majority of instances such an abscess 
is due to imperfect treatment, but in many cases the canal of the root is 
so narrow and irregular as to make it almost impossible to fill the canal 
or cavity to the apex. When a case presents symptoms of a pericemental 
inflammation and the history is uncertain, the most rational procedure 
is first to skiagraph the field, thus ascertaining the exact location and 
extent of the lesion and often its cause. (Fig. 208.) 

Tumors, such as sarcomata or carcinomata, that frequently develop 
in the antrum, can in some cases be demonstrated by careful X-ray exam- 
inations. A cavity that is free from pus, blood, other fluid, or tumors 
shows a clearer and more sharply defined shadow than where one of the 
conditions just named is present. 

Orthodontia. In deformities of the jaws due to or associated with 
unerupted teeth, the dental skiagrapher can ascertain with great exact- 
ness the size, shape, and position of the teeth within the bones. 

Occasionally the dentist is called upon to regulate teeth, and before 
so doing it is advisable for him to know the exact position of the roots, 
and also to what extent the tooth canals are closed. If the apex of the 
root is not fully developed, the teeth can be regulated more rapidly 
and without danger of destroying the pulp. 



CHAPTER VIII 

THE RONTGEN RAYS IX FORENSIC MEDICINE. 
I. The Legal Status of the X-Ray. 
A. ADMISSIBILITY ix VARIOUS STATES. 

EVER since Prof. Rontgen's immortal discovery has been applied as 
a diagnostic agent in medicine and surgery, the legal status of the X-ray 
has been argued, denounced, and defended by attorneys the world over. 
It seems most fitting to quote a few lines from the comprehensive contri- 
bution of the Hon. W. W. Goodrich, Presiding Justice, Appellate Divi- 
sion of the Supreme Court of the State of New York, 1 second judicial 
department. 

" The general rule with regard to ordinary photographs has long been 
that, wherever the person or thing would under general rules be relevant 
if produced in court, or the jury would be permitted to see it if conven- 
ient, a photograph of such person or thing, if properly authenticated, is 
admissible when the original cannot be seen. Whenever the jury are 
likely to be materially aided by the opinions, on matters of fact, of per- 
sons specially qualified, they should have them, and, for the purpose of 
illustrating and making clear the testimony of medical and surgical 
experts, photographs taken by the Rontgen or X-ray process have been 
admitted as evidence in the courts of several of the states. A reference 
to these cases will show the present status of the law upon the subject. 
The first case in which the question arose in this country is uureported, 
but there is a summary of it in the Chicago Legal News. It was decided 
in Colorado, in 1896, and, in admitting the X-ray photograph, the learned 
Judge Lefevre said : ' During the last decade at least, no science has 
made such mighty strides forward as surgery. It is eminently a scien- 
tific profession, alike interesting to the learned and unlearned. It makes 
use of all science and learning. It has been of inestimable value to man- 
kind. It must not be said of the law that it is wedded to precedent ; 
that it will not lend a helping hand. Rather, let the courts throw open 
the door to all well-considered scientific discoveries. Modern science has 
made it possible to look beneath the tissues of the human body, and has 
aided surgery in telling of the hidden mysteries. We believe it to be our 
duty in this case to be the first, if you please to so consider it, in admit- 
ting in evidence a process known and acknowledged as a determinate 
science.' " 

Probably the leading case in this country on the subject under dis- 
cussion is that of Bruce vs. Beall (99 Tenn. 303), decided September 30, 

1 Brooklyn Medical Journal, December, 1903. 

375 



37G ELECTRO-THERAPEUTICS. 

1897. Judge Beard, writing for the Court, said: "In the progress of 
the trial, one Dr. Galtman was introduced as a witness, and he was per- 
mitted to submit to the jury an X-ray photograph, taken by him, show- 
ing the overlapping bones of one of the plaintiffs legs, at a point where 
it was broken by this fall. This was objected to by the defendant's 
counsel. This picture was taken by the witness, who was a physician and 
surgeon, not only familiar with fractures, but with the new and interesting 
process by which this particular impression was secured. He testified, 
that this photograph accurately represented the condition of the leg at 
the point of the fracture in question, and, as a fact, that by the aid of 
X-rays he was enabled to see the broken and overlapping bones with his 
own eyes, exactly as if, stripped of the skin and tissues, they were 
uncovered to the sight. We might, if we so desired, rest our conclusion 
on the general character of the exception taken to this testimony, but we 
prefer to place it on the ground that, verified as was this picture, it 
was altogether competent for the purpose for which it was offered. New 
as this process is, experiments made by scientific men, as shown by this 
record, have demonstrated its power to reveal to the natural eye the 
entire structure of the human body, and that its various parts can be 
photographed, as its exterior surface has been, and now is." 

It is the opinion of some of the judges of Massachusetts, that X-ray 
photographs are not admissible as evidence, contending that as cold 
scientific truths they cannot be regarded as accurate. No one can posi- 
tively attest to the absolute correctness of the reproduction. The truth- 
fulness of the photograph is a matter of reasoning. In the Philadelphia 
courts, the skiagram is admitted as corroborative evidence, provided that 
it has been executed by an expert in the work ; the same ruling is in force 
in the English courts. In Nebraska, the courts of final jurisdiction main- 
tain that skiagrams must be taken by competent persons, who must be 
able authoritatively and indisputably to assert, that the appearances 
shown are accurate representations of the part. 

In a malpractice suit, Carlson vs. Benton, in a Nebraska court, it was 
decided by the judge that a skiagram could be introduced as evidence, 
despite the fact that the skiagrapher was not experienced in this special 
field of work. 

In this case, an X-ray photograph of an injured leg, taken after the 
injury had been treated by the defendant, was offered in evidence. The 
uncontradicted testimony of three surgeons left no room for a difference 
of opinion as to the accuracy of the photograph, the court maintaining 
that to exclude, under such circumstances, the skiagram as evidence, on 
the ground that a sufficient foundation had not been laid, was an abuse 
of discretion. 

In medico-legal cases the X-rays are of inestimable value to the phy- 
sician or surgeon in sustaining a diagnosis, to the patient who is insti- 
tuting the suit, and, lastly, and probably most important, to the judge 



THE RONTGEN RAYS IN FORENSIC MEDICINE. 377 

and jury, to whom medical terms and expressions are often so wholly 
unintelligible. A skiagram of good "definition' 1 can be fairly well 
interpreted by the average layman, and it will often assist an attorney in 
determining whether a case should be compromised or carfied to court. 

The courts are always disposed to permit an exposition of scientific 
methods that will elucidate the intricate questions submitted for judg- 
ment. In certain tribunals, where the skiagram is rigorously excluded, 
fluoroscopic examinations in the presence of the judge and jury are 
permitted, and the knowledge gained therefrom is counted as evidence. 

The physician or surgeon (and this applies especially to the 
beginner) should always be guarded in expressing a positive opinion, as 
to the results that may be expected, after a difficult fracture, such as one 
involving the elbow, or the likelihood of the absence of deformity in a 
fractured clavicle, or the prevention of limping after fracture of the 
femur, etc. In any case where serious deformity and inconvenience may 
or may not result, that physician is wisest who ventures only the truth, 
explaining the probable results and informing the sufferer and his 
friends that he will do the very best he can under the circumstances. 
In those cases where one is quite